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Case 324.

Pokhraj Prakashchandra Suthar¹, Kathryn Hughes¹, Mustafa Mafraji¹

¹From the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612.

|December 19, 2023

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A 69-year-old male presented with unresponsiveness due to polysubstance intoxication, including cocaine, marijuana, fentanyl, and benzodiazepines. Despite naloxone, he remained unresponsive, requiring intubation and advanced neuroimaging.

Area of Science:

Neurology
Toxicology
Emergency Medicine

Background:

A 69-year-old male with a history of substance use disorder presented with unresponsiveness.
Vital signs were largely stable, but Glasgow Coma Scale score was 8.
Routine laboratory work-up was largely unremarkable except for elevated creatine kinase and liver enzymes.

Purpose of the Study:

To investigate the cause of unresponsiveness in a patient with polysubstance intoxication.
To rule out acute intracranial abnormalities.
To assess for potential neurological sequelae of substance use.

Main Methods:

Physical examination and vital signs assessment.
Comprehensive laboratory work-up, including toxicology screening.

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Electrocardiogram (ECG) and echocardiogram.

Noncontrast and contrast-enhanced CT of the head and CT angiography.

Multisequence MRI of the brain with intravenous contrast.

Main Results:

Urine drug screening was positive for cocaine, marijuana, fentanyl, and benzodiazepines.
Elevated creatine kinase (49,006 U/L) and liver enzymes (ALT 126 U/L, AST 488 U/L) were noted.
Neuroimaging (CT and MRI) was performed to evaluate for intracranial pathology.

Conclusions:

The patient's unresponsiveness was attributed to polysubstance intoxication.
Advanced neuroimaging was crucial in ruling out structural brain abnormalities.
Management involved airway protection and supportive care in the emergency department.