Tox Case...I think

[wareagle726]

Okay so here's a case I had. I think it was too. Smelled like tox. Would love some thoughts.

20ish year old male no hx came in after roommates found him "altered." EMS said they saw seizure-like activity and had a bottle of Delta-8 in the room.
On arrival, will make eye contact occasionally but is on another world. Think ketamine. Also thrashing in the bed. No clonus/ridigity. Moving all extremities. Moves neck without difficulty.
HR 170's(sinus as far as I could tell), BP 230/160. ) O2 97 RA, RR 35, T 101F.
Took four security guards to hold down. Gave 6mg IM ativan(2 doses of 3mg) with no improvement. I just decided to tube him or else we were never gonna get line or a workup.
VS improved with sedation, including temp.
Abnormal labs were Cr of 2.7, Lactic of 5.5, CK of 550
Really abnormal labs were WBC 50.4k, Ammonia 355.
UDS positive for pot only.
No reports of SI. No history of being on valproic acid. History of 2 episodes of AMS due to spice.

Like I said all points to tox. Covered for meningitis just in case.

I just haven't seen a WBC or ammonia that high from tox. Someone smarter please give me some insight.

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[Zebra Hunter]

Did you call poison control? Would’ve been interesting to see whether the toxicologist had seen similar case presentations with synthetic cannibinoids.

 

[Tipsy McStagger]

What was the rest of the CMP? Any cell lines down in the CBC? In the spirit of thinking outside the box, I've seen similar things with Leukemia.

Tox is likely, synthetic/designer drugs can do the above though I haven't seen hyperammonemia that I recall off the top of my head.

More labs please

 

[wareagle726]

Did you call poison control? Would’ve been interesting to see whether the toxicologist had seen similar case presentations with synthetic cannibinoids.

Yea spoke with PC and requested on-call toxicologist. She said the hyperammonemia and leukocytosis could be due to prolonged seizures and isn't out of the realm of possibility of sympathomimetics. Wanted to trend of course.

What was the rest of the CMP? Any cell lines down in the CBC? In the spirit of thinking outside the box, I've seen similar things with Leukemia.

Tox is likely, synthetic/designer drugs can do the above though I haven't seen hyperammonemia that I recall off the top of my head.

More labs please

These are to the best of my remembrance. Most of which I just remember as WNL.
Na - WNL
K - 4.2
CO2 - 20
CL - WNL(Maybe a tick low?)
Gluc - 150s
Cr - 2.7
BUN - 18-20 maybe? not high though I remember that for sure
Bili - <1 don't remember exactly
Alk Phos - WNL
ALT - 140s
AST - upper 300s

I don't remember exact numbers on the LFTs but I remember it being an alcoholic type picture... which reminds me

EtOH - neg
ASA - neg
APAP - neg

I think the gap was around 16-18 but I concluded probably due to the lactic.

Nothing else stands out in memory on the CBC. Maybe a little anemic. Neutrophils were like 85%. Can't remember the rest.

 

[Tipsy McStagger]

Yea spoke with PC and requested on-call toxicologist. She said the hyperammonemia and leukocytosis could be due to prolonged seizures and isn't out of the realm of possibility of sympathomimetics. Wanted to trend of course.


These are to the best of my remembrance. Most of which I just remember as WNL.
Na - WNL
K - 4.2
CO2 - 20
CL - WNL(Maybe a tick low?)
Gluc - 150s
Cr - 2.7
BUN - 18-20 maybe? not high though I remember that for sure
Bili - <1 don't remember exactly
Alk Phos - WNL
ALT - 140s
AST - upper 300s

I don't remember exact numbers on the LFTs but I remember it being an alcoholic type picture... which reminds me

EtOH - neg
ASA - neg
APAP - neg

I think the gap was around 16-18 but I concluded probably due to the lactic.

Nothing else stands out in memory on the CBC. Maybe a little anemic. Neutrophils were like 85%. Can't remember the rest.

If he'd been seizing so much that his ammonia and wbc were that high I'd expect a lactic acidosis and his CO2 to be much lower, but that's just a hypothesis. Elevated liver enzymes and normal bili with elevated Nh3... hmm

I don't know what's up, but I'm gonna look at this later after I get drunk. It's been a long week.

 

[wareagle726]

Please do. That usually gives me some better insight after a long week. I know we "learn" new things all the time but this one had me particularly puzzled. I'm out of the country for the next week but I'll pull up the chart when I get back and have some answers hopefully. My luck it's probably some ridiculous low penetrance ornithine transcarbamylase deficiency that just now surfaced or something else that's never been heard of by anyone on this forum.

Alternatively I just missed something....

 

[Mount Asclepius]

I’ve had a few similar-ish cases over the years. Not diminishing the inpatient side in the least bit, but there’s a good chance you’ll end up disappointed not finding an answer. When you log back in you might see that the LP and MRI +/- EEG and neuro/tox/psych consults were inconclusive with non-specific findings and vague opinions. Patient self extubates and leaves AMA in 24-72 hours. Everyone is like 🤷‍♂️ Drugs?…

For sure enjoy the academic thought challenge though.

 

[dr.z]

Organic acidemias or urea cycle disorder. Check plasma amino acids, acylcarnitine profile, urine organic acids, MMA, B12, folate, and homocysteine.

 

[CajunMedic]

I was still on the ambulance during the "mojopocalypse", and saw a few cases similar to this. n=1, but this seems like synthetic cathinone/bath salts.

When you log back in you might see that the LP and MRI +/- EEG and neuro/tox/psych consults were inconclusive with non-specific findings and vague opinions. Patient self extubates and leaves AMA in 24-72 hours. Everyone is like 🤷‍♂️ Drugs?…

Always seems to be the most common disposition. Had a bad batch of something come through early in my attendinghoood. Narcotic toxidrome but up to 18-20mg of Naloxone wouldn't touch it. Gets intubated, boards in the ED for 18 hours, self-extubates and wanders out, found nodding on a bench on the campus and brought back in by security-lather, rinse, repeat

 

[WilcoWorld]

Hyperammonemia suggests something interfering with the carnitine cycle. Main tox thing I know to do that is valproic acid toxicity, but that doesn't explain the vitals/WBC, so I don't think it's VPA, but something else that interferes with the carnitine cycle.

 

[thegenius]

Okay so here's a case I had. I think it was too. Smelled like tox. Would love some thoughts.

20ish year old male no hx came in after roommates found him "altered." EMS said they saw seizure-like activity and had a bottle of Delta-8 in the room.
On arrival, will make eye contact occasionally but is on another world. Think ketamine. Also thrashing in the bed. No clonus/ridigity. Moving all extremities. Moves neck without difficulty.
HR 170's(sinus as far as I could tell), BP 230/160. ) O2 97 RA, RR 35, T 101F.
Took four security guards to hold down. Gave 6mg IM ativan(2 doses of 3mg) with no improvement. I just decided to tube him or else we were never gonna get line or a workup.
VS improved with sedation, including temp.
Abnormal labs were Cr of 2.7, Lactic of 5.5, CK of 550
Really abnormal labs were WBC 50.4k, Ammonia 355.
UDS positive for pot only.
No reports of SI. No history of being on valproic acid. History of 2 episodes of AMS due to spice.

Like I said all points to tox. Covered for meningitis just in case.

I just haven't seen a WBC or ammonia that high from tox. Someone smarter please give me some insight.

I think it's 100% tox, unlikely meningitis but I guess you have to do an LP. A BP of 230/160 (if that were true) seems inconsistent. I would be pushing, as you did, versed until he calmed down. And if he didn't, I would be giving propofol until calmed down. (oh wait..you didn't have a line!)
well done, good case. Just disappointing we probably shall never know what it was. What is Delta-8?

 

[RustedFox]

I have seen WBC counts in the 20-30 range with bad cases of cannabinoid hyperemesis syndrome. I know because I've seen them bounce back for other reasons between visits for CHS and have normal white counts.

Like:

Jan 12 - visit for ankle sprain. Normal WBC.
Feb 18 - visit for CHS. WBC = 22.9
Feb 28 - visit for dysuria/UTI. Normal WBC.
Mar 31 - visit for assault. Normal WBC.
Apr. 11 - visit for CHS. WBC = 27.6
June 6 - visit for whatever. Normal WBC.

 

[WilcoWorld]

I have seen WBC counts in the 20-30 range with bad cases of cannabinoid hyperemesis syndrome. I know because I've seen them bounce back for other reasons between visits for CHS and have normal white counts.

Like:

Jan 12 - visit for ankle sprain. Normal WBC.
Feb 18 - visit for CHS. WBC = 22.9
Feb 28 - visit for dysuria/UTI. Normal WBC.
Mar 31 - visit for assault. Normal WBC.
Apr. 11 - visit for CHS. WBC = 27.6
June 6 - visit for whatever. Normal WBC.

Here's where the thread stops being about the tox case and starts being about criticizing you for ordering a CBC on an ankle sprain.

 

[Mount Asclepius]

Here's where the thread stops being about the tox case and starts being about criticizing you for ordering a CBC on an ankle sprain.

It was the midlevel that the CMG made him supervise

 

[Radetzky]

What happened to him. Did the ammonia come down by itself or did they have to dialyse?

 

[RustedFox]

Here's where the thread stops being about the tox case and starts being about criticizing you for ordering a CBC on an ankle sprain.

Touché.

 

[RustedFox]

It was the midlevel that the CMG made him supervise

Double touché.

Maybe not ankle sprain; maybe fever/flu.
But seriously, you guys get the idea.

 

[Apollyon]

Psilocybin? Other mushrooms? Did Cr normalize?

 

[lucid_leprechaun]

I think it's 100% tox, unlikely meningitis but I guess you have to do an LP. A BP of 230/160 (if that were true) seems inconsistent. I would be pushing, as you did, versed until he calmed down. And if he didn't, I would be giving propofol until calmed down. (oh wait..you didn't have a line!)
well done, good case. Just disappointing we probably shall never know what it was. What is Delta-8?

It certainly sounds toxic. I will say sometimes I’m these Benzo refractory cases antidopaminergic meds are the answer. I’ve certainly seen very effective with the various sympathomimetics currently sold as meth

The acute effect of cannabis on plasma, liver and brain ammonia dynamics, a translational study

Recent reports of ammonia released in high concentrations during cannabis smoking raise concerns about putative neurotoxic effects. Cannabis (54mg) was administered in a double-blind, placebo-controlled design to healthy cannabis users (n=15) either orally, ...

www.ncbi.nlm.nih.gov

 

[BoardingDoc]

It certainly sounds toxic. I will say sometimes I’m these Benzo refractory cases antidopaminergic meds are the answer. I’ve certainly seen very effective with the various sympathomimetics currently sold as meth

The acute effect of cannabis on plasma, liver and brain ammonia dynamics, a translational study

Recent reports of ammonia released in high concentrations during cannabis smoking raise concerns about putative neurotoxic effects. Cannabis (54mg) was administered in a double-blind, placebo-controlled design to healthy cannabis users (n=15) either orally, ...

www.ncbi.nlm.nih.gov

I don't even bother with repeated doses of benzos anymore for general agitated delirium. If they're with it and just need some calming down, sure they get some Ativan. If it doesn't work or they're proper agitated, they get 10 of droperidol and 5 of versed.

 

[TooMuchResearch]

I think it's 100% tox, unlikely meningitis but I guess you have to do an LP. A BP of 230/160 (if that were true) seems inconsistent. I would be pushing, as you did, versed until he calmed down. And if he didn't, I would be giving propofol until calmed down. (oh wait..you didn't have a line!)
well done, good case. Just disappointing we probably shall never know what it was. What is Delta-8?

It's an over the counter cannabinoid widely used in states where you can't just buy marijuana. They also sell delta 9 and I saw an ad for Delta 10.


Also for this particular case: Dude was on drugs. Probably not just Delta 8.

 

[Rekt]

Where I trained delta 8 was huge. Mostly benign but very often saw people come in with severe altered mental status and often with seizures. And sometimes in status. Only thing positive was ThC. Usually they’d bring a package of what looks like candy rope/big edibles and freind/family would say they ate the whole thing. I had one i tubed, central line, dialysis line for a pH of 6.6 with ammonia >700. Sent for emergent dialysis due to pH. He extubated himself and pulled his dialysis line out and left ama telling everyone to fk off 6-8 hours later

 

[Tipsy McStagger]

Where I trained delta 8 was huge. Mostly benign but very often saw people come in with severe altered mental status and often with seizures. And sometimes in status. Only thing positive was ThC. Usually they’d bring a package of what looks like candy rope/big edibles and freind/family would say they ate the whole thing. I had one i tubed, central line, dialysis line for a pH of 6.6 with ammonia >700. Sent for emergent dialysis due to pH. He extubated himself and pulled his dialysis line out and left ama telling everyone to fk off 6-8 hours later

nice. probably what was going on with this guy I'd guess. gnarly stuff

 

[wareagle726]

Organic acidemias or urea cycle disorder. Check plasma amino acids, acylcarnitine profile, urine organic acids, MMA, B12, folate, and homocysteine.

Hopefully the inpatient team did all this. I'm not that smart and they were admitted way before you suggested it.

I don't even bother with repeated doses of benzos anymore for general agitated delirium. If they're with it and just need some calming down, sure they get some Ativan. If it doesn't work or they're proper agitated, they get 10 of droperidol and 5 of versed.

He was so agitated I couldn't even get a reliable EKG so didn't feel comfortable giving haldol or drop. Maybe I'm too conservative. I just had no I dead what was going on so he got a breathing noodle.

Where I trained delta 8 was huge. Mostly benign but very often saw people come in with severe altered mental status and often with seizures. And sometimes in status. Only thing positive was ThC. Usually they’d bring a package of what looks like candy rope/big edibles and freind/family would say they ate the whole thing. I had one i tubed, central line, dialysis line for a pH of 6.6 with ammonia >700. Sent for emergent dialysis due to pH. He extubated himself and pulled his dialysis line out and left ama telling everyone to fk off 6-8 hours later

This makes me feel better. Don't know what happened to him yet. Currently on a big boat out in the deep blue sea so I can't log in to tell the end of the story.

 

[RustedFox]

"Breathing noodle".

I wish I had though of that'n. Lol.

 

[BoardingDoc]

He was so agitated I couldn't even get a reliable EKG so didn't feel comfortable giving haldol or drop. Maybe I'm too conservative. I just had no I dead what was going on so he got a breathing noodle.

Interesting. I don't get an EKG before I give people meds like drop or zofran. And I mean, unless you tell me you have a long qt, i basically never do it. I'd personally see the risk of giving drop as much lower than the risks involved in intubation. Curious what others think.

 

[Rekt]

Interesting. I don't get an EKG before I give people meds like drop or zofran. And I mean, unless you tell me you have a long qt, i basically never do it. I'd personally see the risk of giving drop as much lower than the risks involved in intubation. Curious what others think.

Absolutely not. Where I trained we used droperidol like water and never had issues. The hospital I’m currently at, pharmacy will refuse drop without ecg, but we can shower them in haldol which has more qt prolongation than droperidol anyway.

 

[WilcoWorld]

Interesting. I don't get an EKG before I give people meds like drop or zofran. And I mean, unless you tell me you have a long qt, i basically never do it. I'd personally see the risk of giving drop as much lower than the risks involved in intubation. Curious what others think.

Single dose use? No issues. The case reports/series that got droperidol it's black box warning were using doses 10X what you'd start with in the ED.

 

[wook]

On physical exam was there nystagmus? Usually with ketamine you will see this.

What did the pupils look like? With stims you will often see large pupils. Same with THC..

What was the patients temperature?

Was there clonus (had a likely serotonin syndrome that had clonus and was really altered)?

 

[PianoMedic]

On physical exam was there nystagmus? Usually with ketamine you will see this.

What did the pupils look like? With stims you will often see large pupils. Same with THC..

What was the patients temperature?

Was there clonus (had a likely serotonin syndrome that had clonus and was really altered)?

Excellent questions. I’ve had some bizarro cases recently with people using herbal supplements that interacted with their normal meds, one of which was serotonin syndrome from ashwagandha and lexapro.

Agree on droperidol and QTc: if I would check it before giving something like zofran then and only then will I check an ekg (patient on high dose methadone, has 8 mg zofran at home they’ve been eating like candy and still puking, known long QTc in the past, etc). If I normally wouldn’t check an ekg, say agitation, migraine, nausea/vomiting, then I won’t check it. If I’ve given many doses of meds and this is rescue therapy, I also would probably check, just as I would with haldol as rescue for cannabinoid hyperemesis. Some of our psych and IM docs check an ekg prior to any QT prolonging med which seems like overkill to me.

 

[wareagle726]

Interesting. I don't get an EKG before I give people meds like drop or zofran. And I mean, unless you tell me you have a long qt, i basically never do it. I'd personally see the risk of giving drop as much lower than the risks involved in intubation. Curious what others think.

Normally I wouldn't care. In this care where I didn't know what was going on I gave it more thought. When I'm going down the undifferentiated tox algorithm I'm hesitant to give QT prolonging meds just out of a fear of what I don't know.

On physical exam was there nystagmus? Usually with ketamine you will see this.

What did the pupils look like? With stims you will often see large pupils. Same with THC..

What was the patients temperature?

Was there clonus (had a likely serotonin syndrome that had clonus and was really altered)?

Maybe I didn't post above. No nystagmus whatsoever. Pupils were approx 5 and reactive bilaterally. Temp 98 initially up to 101 then down to 98 again through foley temp. No clonus or rigidity to suggest Serotonin syndrome or NMS. Thought about those on initial presentation.

 

[Mount Asclepius]

Fearing QT prolongation is overrated.

Drop and Haldol will make your shifts much better. Can we nebulize them yet?

 

[turkeyjerky]

Fearing QT prolongation is overrated.

Drop and Haldol will make your shifts much better. Can we nebulize them yet?

Seriously, definitely not the reason to avoid using haldol in tox cases.

 

[thegenius]

Interesting. I don't get an EKG before I give people meds like drop or zofran. And I mean, unless you tell me you have a long qt, i basically never do it. I'd personally see the risk of giving drop as much lower than the risks involved in intubation. Curious what others think.

don't have droperidol. certainly not for zofran. If I give 5 or more of haldol I get an EKG.

 

[PianoMedic]

don't have droperidol.

I couldn’t work at that shop.

 

[wareagle726]

Seriously, definitely not the reason to avoid using haldol in tox cases.

I mean that's fair. If they happened to OD on a TCA or aniticholinergic(which is kinda how he looked) or whatever then you might push them over the edge. It's not my common practice to be fearful of drop/haldol but I had no idea what was happening with this guy.

 

[GoBuckeyes913]

Okay so here's a case I had. I think it was too. Smelled like tox. Would love some thoughts.

20ish year old male no hx came in after roommates found him "altered." EMS said they saw seizure-like activity and had a bottle of Delta-8 in the room.
On arrival, will make eye contact occasionally but is on another world. Think ketamine. Also thrashing in the bed. No clonus/ridigity. Moving all extremities. Moves neck without difficulty.
HR 170's(sinus as far as I could tell), BP 230/160. ) O2 97 RA, RR 35, T 101F.
Took four security guards to hold down. Gave 6mg IM ativan(2 doses of 3mg) with no improvement. I just decided to tube him or else we were never gonna get line or a workup.
VS improved with sedation, including temp.
Abnormal labs were Cr of 2.7, Lactic of 5.5, CK of 550
Really abnormal labs were WBC 50.4k, Ammonia 355.
UDS positive for pot only.
No reports of SI. No history of being on valproic acid. History of 2 episodes of AMS due to spice.

Like I said all points to tox. Covered for meningitis just in case.

I just haven't seen a WBC or ammonia that high from tox. Someone smarter please give me some insight.

Delta-8 is an isomer of Delta-9, the only difference is the location of a double-bond between two carbons. These alone are not the problems.

What independent analysis of thousands of the delta gummies have found is that there are often toxic solvents used ( or end up as by products) along with more than a handful of other identified compounds. To synthesize Delta 8, it takes a strong acid. These companies could also be using a strong base to neutralize—- or not. We don’t know, that’s the horrifying part and patients end up being the guinea pigs. The companies that make these products are unregulated, and they certainly aren’t using mass spec and testing final pH to see what their final product contains.

That being said, some have some pretty nasty solvents in them, I.e. toluene, that can cause hepatorenal toxicity, CNS issues. You’d have to send the exact package of delta 8 for analytics to see what comes up on mass spec….. and even then some of it won’t be identifiable. Some of the gummies when tested can have up to 30 unidentifiable points on mass spec. It’s alarming. From a clinical standpoint, just know that these products can contain some nasty solvents and those are what is likely giving you all the wrong lab numbers.

It’s like bath salts 2.0.

Hope this helps.

 

[wareagle726]

Delta-8 is an isomer of Delta-9, the only difference is the location of a double-bond between two carbons. These alone are not the problems.

What independent analysis of thousands of the delta gummies have found is that there are often toxic solvents used ( or end up as by products) along with more than a handful of other identified compounds. To synthesize Delta 8, it takes a strong acid. These companies could also be using a strong base to neutralize—- or not. We don’t know, that’s the horrifying part and patients end up being the guinea pigs. The companies that make these products are unregulated, and they certainly aren’t using mass spec and testing final pH to see what their final product contains.

That being said, some have some pretty nasty solvents in them, I.e. toluene, that can cause hepatorenal toxicity, CNS issues. You’d have to send the exact package of delta 8 for analytics to see what comes up on mass spec….. and even then some of it won’t be identifiable. Some of the gummies when tested can have up to 30 unidentifiable points on mass spec. It’s alarming. From a clinical standpoint, just know that these products can contain some nasty solvents and those are what is likely giving you all the wrong lab numbers.

It’s like bath salts 2.0.

Hope this helps.

Very insightful. Thanks. That does make alot of sense if these peeps are ingesting a bunch of different solvents and whatnot.

 

[WilcoWorld]

Delta-8 is an isomer of Delta-9, the only difference is the location of a double-bond between two carbons. These alone are not the problems.

What independent analysis of thousands of the delta gummies have found is that there are often toxic solvents used ( or end up as by products) along with more than a handful of other identified compounds. To synthesize Delta 8, it takes a strong acid. These companies could also be using a strong base to neutralize—- or not. We don’t know, that’s the horrifying part and patients end up being the guinea pigs. The companies that make these products are unregulated, and they certainly aren’t using mass spec and testing final pH to see what their final product contains.

That being said, some have some pretty nasty solvents in them, I.e. toluene, that can cause hepatorenal toxicity, CNS issues. You’d have to send the exact package of delta 8 for analytics to see what comes up on mass spec….. and even then some of it won’t be identifiable. Some of the gummies when tested can have up to 30 unidentifiable points on mass spec. It’s alarming. From a clinical standpoint, just know that these products can contain some nasty solvents and those are what is likely giving you all the wrong lab numbers.

It’s like bath salts 2.0.

Hope this helps.

Tremendously helpful - makes so much more sense than the idea that there's some gorilla THC with horns that does all sorts of totally novel things to patients.

 

[bravotwozero]

Delta-8 is an isomer of Delta-9, the only difference is the location of a double-bond between two carbons. These alone are not the problems.

What independent analysis of thousands of the delta gummies have found is that there are often toxic solvents used ( or end up as by products) along with more than a handful of other identified compounds. To synthesize Delta 8, it takes a strong acid. These companies could also be using a strong base to neutralize—- or not. We don’t know, that’s the horrifying part and patients end up being the guinea pigs. The companies that make these products are unregulated, and they certainly aren’t using mass spec and testing final pH to see what their final product contains.

That being said, some have some pretty nasty solvents in them, I.e. toluene, that can cause hepatorenal toxicity, CNS issues. You’d have to send the exact package of delta 8 for analytics to see what comes up on mass spec….. and even then some of it won’t be identifiable. Some of the gummies when tested can have up to 30 unidentifiable points on mass spec. It’s alarming. From a clinical standpoint, just know that these products can contain some nasty solvents and those are what is likely giving you all the wrong lab numbers.

It’s like bath salts 2.0.

Hope this helps.

Maan, they’d be safer just eating caanabis laced brownies..

 

[wareagle726]

Maan, they’d be safer just eating caanabis laced brownies..

We actually had two "delta-8's" that night. The commonly repeated statement from staff was, agree or disagree with it's implications, was "whatever happened to just smoking a normal joint" lol

 

[WilcoWorld]

No question that weed is safer than the synthetic stuff.

 

[gutonc]

No question that weed is safer than the synthetic stuff.

Anyone wonder if we'd have meth, fentanyl and all this other ridiculous synthetic s*** (and all of the downstream issues) if we'd just left coke and heroin (never mind weed) alone?

People have been getting high for millenia, and they're not going to stop just because the gummint says they shouldn't. Our current "drug problem" is the predictable result of 50+ years of ridiculous and misguided policy.