A 25-year-old female was brought to the emergency department with a history of nausea, vomiting, dizziness, abdominal pain, and altered sensorium. She was weighing around 55 kgs. She had given history of ingestion of two bottles (refills) of mosquito repellent available in the house, 2 h before she was brought to the hospital. (Each refill containing 45 ml (396 mg) transfluthrin). On examination, patient was conscious, pupils bilaterally semi constricted and sluggishly reactive to light. On auscultation of lungs crepitations were present bilaterally. Respiratory rate was 28/min. Blood pressure was 110/70 mmHg. In emergency ward, gastric lavage was performed and then continuous gastric aspiration was started through Ryles tube. Oral syrup charcoal 10 ml was given, and Ryles tube was closed at proximal end for some time. Then again aspiration through Ryles tube was continued. Atropine 0.6 mg, pantoprazole 40 mg and ondansetron 4 mg were given intravenously. Tonic-clonic convulsions were observed after 1 h of admission in the emergency ward. Injection phenytoin 700 mg bolus, injection diazepam 10 mg, injection hydrocortisone 100 mg, injection frusemide 20 mg, were administered intravenously. Oxygen enrichment was continued. However, patient had continuous uncontrolled convulsions. Then patient was shifted to intensive care unit and midazolam 5 mg and propofol 100 mg (80 mg + 20 mg) were administered intravenously. Endotracheal intubation was successfully performed with 7.5 mm ID endotracheal tube, and cuff was inflated and oxygen enrichment at 4–6 L/min via T-piece was initiated. Midazolam 4 mg/h and propofol 200 mg/h IV infusions were started. SpO2 was maintained at 100%. Blood pressure was 94/62 mmHg. Pulse rate was 74/min. Arterial blood gas (ABG) reports were normal. Neurophysician advised IV mannitol (20%)100 ml twice a day and IV phenobarbitone (SOS) for seizures.\nPatient was seizure free for few hours but again seizures started, and not controlled even with repeat doses of phenytoin, midazolam, propofol, and phenobarbitone. At that time blood pressure was 80/40 mm of Hg, respiratory rate was 35/min, pulse rate was 190/min, and SpO2 was 95%. Serum potassium, calcium, and sodium were 2.98 mmol/L, 2.5 mmol/L and 129 mmol/L, respectively. Injection dopamine was started at 10 μgm/kg/min. Potassium chloride 1.5 g and hypertonic saline were administered. Despite repeated doses of phenytoin, midazolam, propofol and phenobarbitone, seizures were not controlled. Elective ventilation was planned after muscle paralysis to control seizures. Patient was paralyzed by injection vecuronium 4 mg bolus and 4 mg/h IV infusion , and put on controlled mechanical ventilation (CMV) mode for elective ventilation. Vecuronium was continued at 4 mg/h. Blood pressure further decreased gradually and dopamine dose was increased and propofol infusion was stopped. ABG reports did not show any changes. Computed tomography scan of brain and chest X-ray were normal. Input/output charting for fluids was maintained. Central venous pressure remained at 5-8 cm H2O. Patient was kept on a ventilator for 48 h electively and then gradually weaning started. Vecuronium and midazolam infusion were stopped, and mode of ventilation was changed to synchronized intermittent mandatory ventilation (SIMV). Airway pressure support was set to 15 cm H2O with positive end expiratory pressure of 4 cm H2O. Patient's pulse rate was 102 beats/min, blood pressure 132/82 mmHg and SpO2 remained above 96%.\nPatient had total leucocyte count on day 1 of 7200/mm3 and it increased to 22,000/mm3 on the day 2, 32,000/mm3 on the day 3 and 13,000/mm3 on the day 4, all with neutrophilia without other signs of septicaemia, although antibiotics were continued. The counts decreased to 4000/mm3 on day 6. After 48 h on ventilator, dopamine infusion was tapered down in next 6 h and then stopped. About 6 h on SIMV mode, spontaneous respiration was noticed at 16 breaths/min. Muscle relaxation was reversed with inj. neostigmine 2.5 mg and inj.glycopyrrolate 0.4 mg. Patient started breathing spontaneously with adequate tidal excursion and followed verbal commands and then extubated. Oxygen through mask was given at flow of 4–5 L/min. Respiratory rate was 25 breaths/min, blood pressure was 108/72 mmHg and pulse rate, 119/min. Pupils were normally reacting to light. Patient was nebulised with mistabron 3 mg, repeated 8 hourly. Patient was referred to psychiatrist for counselling. On the day 4, patient was shifted to ward and discharged uneventful from hospital on 7th day.
Mr. A, a 22-year-old Hispanic male with past psychiatric history of methamphetamine dependence and bipolar disorder type 1, came to the emergency department because of suicidal ideation with a plan to slash his throat with a machete. The patient was very agitated in triage and during initial assessment. In the emergency room (ER), the patient reported that he had been using methamphetamine for the last two years. His last use was a few hours before coming to the ER and that was his only use during the past six to eight weeks.\nOn physical examination, temperature was found to be 96.5 degree Fahrenheit, pulse 105/minute, blood pressure 124/78 mm Hg, weight 68.0 kg, and height 173 cm. His pupils were 5 mm in diameter and reactive. In the review of systems, the patient denied any pulmonary, cardiac, renal, and abdominal complaints. There was no increased lacrimation. Lungs were clear and the heart rate was regular without murmurs. Bowel sounds were normoactive. The patient was not oriented to time. His affect was flat and irritable. He was evasive and tangential while answering questions. A chest radiograph and electrocardiogram were normal. His urinary drug screen was positive for amphetamines, methamphetamines, and cannabinoids. Blood chemistry concentrations/counts/percent of the following analyses were mainly within reference limits: alcohol <5 mg/dL, salicylate <4 mg/dL, sodium 141 mmol/L, potassium 3.8 mmol/L, chloride 107 mmol/L, blood urea nitrogen 10 mg/dL, creatinine 0.9 mg/dL, aspartate transaminase 23 U/L, alanine transaminase 18 U/L, alkaline phosphatase 69 U/L, thyroid stimulating hormone 0.57 μIU/mL, white blood cells 10.7 K/uL, red blood cells 4.49 Mu/L, haemoglobin 13.9 g/dL, hematocrit 42.2%, and platelets 239 K/uL. Urinalysis revealed nothing abnormal.\nThe patient was transferred to the inpatient psychiatry unit. The next day, the patient was disoriented, refused to talk to the treatment team, and slept most of the day. On his third hospital day, the patient was much more oriented and reported that he was unable to get methamphetamine for the past six to eight weeks because he could not afford it. He claimed to use an insecticide, mostly cockroach killer, to “get high.” He would either “electrocute” the bottle or spray it on a heated metal sheet, and when the contents of the bottle turned into crystal, he would either inhale it or smoke it. The patient would use the crystals formed from one bottle for four to seven days. He claimed that his friends used those crystals intravenously after diluting them. The patient reported that it would give him the same high as methamphetamine and he would occasionally have feelings of deja vu. The patient also reported having olfactory hallucinations when he was on “crystal roach killer” but could not elaborate on that. He said that he liked the increase in heart rate and the “rush” he used to get after every use.\nThe patient's last use of the “crystal roach killer” was three days before coming to the ER. The patient reported that he would sleep most of the day when he was using it. He denied unwanted adverse effects during his use except for frequent headaches upon waking up which were relieved by over-the-counter analgesics. The patient had been using the insecticide for six to eight weeks and only used methamphetamine one (1) day before coming to the ER. The patient claimed that he had been compliant with his medications for bipolar disorder until he started using “crystal roach killer.” The patient was taking divalproex sodium 500 mg twice daily and quetiapine extended-release 300 mg at bedtime. He voiced that he, since a few weeks before coming to the ER, got scared that he might get cancer because of the frequent use of the insecticide, which led him to have suicidal ideation.