Name:
A 38-Year-Old with Altered Mental Status
Description:
A 38-Year-Old with Altered Mental Status
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Duration:
T00H06M26S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Harrison's Podclass, Episode 5: A 38-year-old Woman with Altered Mental Status. I'll read the question. A 38-year-old woman is brought to the Emergency Department by her spouse because of decreased mental status. She had knee surgery two days ago and was prescribed oral oxycodone for pain.
CATHY: Her spouse knows that she finished the entire seven-day supply during that day. He denies any seizure activity. They have no other drugs or medications in the house. The patient is afebrile with a blood pressure of 130/75, a heart rate of 70, and respiratory rate of four breaths per minute. Her O2 saturation is 85% on room air. She barely responds to painful stimuli, but moves all four extremities equally. Before we get to the question and the answers, Cathy, what are you thinking so far?
CATHY: What we hear so far is that the patient had a recent orthopedic procedure and she was prescribed oxycodone-- which is an opioid medication-- for seven days. That may be a reasonable duration depending on what the expected recovery is following her surgery, but it's clear from the case discussion that she took too much of it. These drugs work centrally and can cause significant respiratory depression and sedation, which we hear from her exam being that she barely responds to painful stimuli.
CHARLIE: What do you take from her vital signs?
CATHY: The most notable vital sign is that she's hypoxic, with an oxygen saturation of 85% on room air. If we heard about that alone in a post-operative patient after an orthopedic procedure, pulmonary embolism would be high on the differential. But in her case, we also hear she has a very reduced respiratory rate at four breaths per minute, but her blood pressure and heart rate are within normal, and that we wouldn't necessarily expect from a pulmonary embolism. Therefore, I think it's way more likely that her hypoxia is due to hypoventilation and I would expect this to respond to supplemental oxygen.
CHARLIE: A blood gas in this case would be useful to distinguish those two, in that an opioid overdose will typically cause a respiratory acidosis where most cases of pulmonary embolism present with a respiratory alkalosis. So, you suspect an opioid overdose. So, let's go through the question and their answers. The question asks, which of the following medications is most likely to improve her mental status? Option A, albuterol; option B, alvimopan; option C, flumazenil; option D, N-acetylcysteine; or option E, naloxone.
CHARLIE: Which of those will help reverse an opioid overdose?
CATHY: The antidote to opioid overdose is naloxone, which is an opioid antagonist, and that can rapidly reverse the respiratory depression which is causing her hypoventilation, and also the sedation which is causing her decreased mental status. It's commonly used now to treat recreational or illicit or narcotic overdoses, and it can be prescribed to patients at a high risk of overdose, too. The big thing to remember is that it's very short-acting, so she may need repeated doses or a naloxone drip if the half-life of the medication that she took is much longer than the antidote.
CHARLIE: So the answer to this question is D, naloxone-- that's the medication of the ones listed that's most likely to improve the mental status of the patient with any kind of opioid intoxication. But what about the other answers, Cathy?
CATHY: Well, we'll start by just going down the list. So, albuterol is a beta-agonist and that can increase the respiratory rate, but it really won't do anything to help the opioid effect causing sedation, and it really doesn't have a role in opioid overdose. Alvimopan is an oral opioid antagonist, but it really only works on the gut and that's why it's approved for use really just following surgeries. So, it can counteract the peripheral side effects of opioids, such as constipation, but it really doesn't have any central actions.
CATHY: So, in her case, where we're most concerned about her mental status, this wouldn't help at all. Flumazenil is a GABA receptor antagonist, and that's used for benzodiazepine overdose such as Valium or Ativan. A benzo overdose would present similarly to this patient, and the reason that I went with narcotic overdose is because we heard from the husband that she had oxycodone in the house and that there were no other medications.
CATHY: So, it's important to think about if there were additional medications that the patient may have taken, but with a good medication history and collateral information, too from the family, I don't suspect that this is playing a role.
CHARLIE: It's important to note that flumazenil can also precipitate seizures, so it should be used very cautiously, and it is typically used on in-patients only as an IV administration. What about N-acetylcysteine?
CATHY: So, that's used for acetaminophen or Tylenol overdose. And the thing to remember, especially as it relates to this case, is that Tylenol or acetaminophen is frequently combined with oxycodone or opioid medications into one pill, so there can be unintentional overdoses that are possible. Clinicians should make sure to check medication bottles or review medication or pharmacy records, to see if Tylenol or acetaminophen was included as a combination pill with opioids. And certainly, if there was any suspicion that there was acetaminophen combined with the opioid medications, or if there are any abnormalities of liver enzymes on lab work, then a Tylenol or acetaminophen level should be checked.
CHARLIE: It's so easy to check one of those levels, that I think any patient with a suspected overdose, it's worth just checking anyway. So, the teaching point in this case is that opioids can cause respiratory depression, hypoxemia, possibly with concurrent hypercarbia if checked by blood gas, and those can be reversed with the short-acting antagonist, naloxone. In addition, clinicians should be very careful to elicit an accurate medication history to make sure there are no other co-ingestions that could be contributing to the presentation.
CATHY: For more information, check out Harrison's Internal Medicine chapter on pain: The Pathophysiology and Management, or the online chapter on opioid-related disorders. I'd also suggest taking a look at the SPACE trial, which was published recently in 2018 in JAMA, which suggests that opioids may not be better than non-opioid pain medications in controlling chronic pain from osteoarthritis.
CHARLIE: Okay, we'll see you next week. ♪ (music) ♪
