What's Your Diagnosis? Methamphetamine Toxicity

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches correct.

Case Presentation: Evidence-Based Emergency Department Management of Methamphetamine Toxicity

The triage nurse asks you for assistance with an agitated patient who is pacing the floor…

When you approach the patient, you find an 18-year-old woman who gives you her name but does not respond appropriately to orienting questions. She is cooperative at first, but then starts to become increasingly agitated when you try to obtain further history.
Her vital signs are: temperature, 37°C; blood pressure, 170/99 mm Hg; heart rate, 120 beats/min; and respiratory rate, 16 breaths/min. She is diaphoretic, but neurologically intact and without any evidence of trauma.
She becomes uncooperative and starts to threaten the staff. Your attempts at de-escalation with redirection and relocation fail, and you wonder what the best pharmacologic intervention would be…

Case Conclusion

The agitated patient was physically restrained and was given 5 mg midazolam IM, and a second dose of 2 mg IM midazolam after 30 minutes, after which her agitation improved. She was monitored on ETCO2 and her restraints were removed once she was interacting appropriately. Laboratory results were unremarkable. On reassessment, she was alert and oriented, ambulatory, and tolerating oral intake. She admitted to using methamphetamine. She was deemed stable for discharge home with family and given resources for outpatient rehabilitation.