SPICE/HEROIN REACTIONS
Chris Kennedy, MD
S
o I have encountered my two sickest
patients in the holding area within
the past 2 weeks or so. One was a
reminder from intern year while looking
through Spice charts, while the other was
an actual patient that I had recently.
We may tend to take the holding area
patients lightly and overlook the potential
for serious illness. I just want to use this as
a warning (especially to the interns) that
sick patients can also use heroin/ETOH/
Spice, so pick up on the small interactions
that don’t go right.
Patient 1 (intern year)
• 46 year old AAM
• CC: Spice OD, Nausea/Vomiting
• Final Diagnosis: Subarachnoid Hemorrhage
• Time to Diagnosis: 7 hours
This patient presented halfway through
my intern year as a Spice reaction. This was
before Spice use was as widespread as it is
now, and no one knew what to expect symptomatically (not that there is ANYTHING
that is characteristic to Spice).
The patient reported that he used Spice
for the first time that night. No significant
PMH. He was on a first date where everything had been going well. He had borrowed
some Spice from his friend to consume at
his home after dinner. Soon after he started
having nausea and projectile vomiting and
was acting ‘goofy.’ His date called EMS and
the date ended.
Exam:
• Gen: Fully A&O, slightly odd in that he
seems incredibly happy to be here
• CV: RRR
• Pulm: CTAB
• ABD: NT/ND
• Neuro: CN II-XII intact, motor intact,
sensation intact, ambulates without difficulty to bathroom
This man was like most of our intoxicated
patients–in need of fluids, food, time and
a “sober re-evaluation.” Approximately 2
hours after arrival he was still vomiting,
so I expanded a medical workup. Due to
his odd behavior plus vomiting, I ordered
a CMP/CBC/Tox screen & CT Head. The
busy night continued and I was caught up
in management of many acute patients as I
waited for his results. He never went for his
CT Head because he was uncooperative, but
I wasn’t told this until hours later. I ordered
ziprasodone and lorazepam but instead of
calming him down he became more agitated
and was no longer oriented. Ultimately we
took him to Room 9 to be intubated prior
to CT and the final diagnosis was made.
Certain forms of Spice that lead to agitation also lead to spikes in blood pressure,
and I found a few case reports of significant
hypertension occurring after Spice use. This
guy had the unfortunate case of rupturing
an aneurysm after using Spice. I’m not sure
if the outcome would have been any different had I reached the diagnosis sooner —
he had many Head CTs and ultimately an
EVD on hospital day 3. This really changed
my perspective on patients being held for
intoxication. He spent 1.5 months in the
hospital (1 month intubated) before being
discharged to rehab.
Patient 2 (PGY3 year)
•
•
•
•
52 year old WM
CC: Heroin OD s/p Narcan
Final Diagnosis: Cardiogenic Shock
Time to Diagnosis: 3.5 hours
This case I handled a bit better (I’d hope
after 2 years). HPI: syncopal episode. EMS
administered naloxone and the patient
woke up. In the ED the patient adamantly
denied heroin use–stated he simply passed
out. Luckily I got to him before EMS left,
and EMS confirmed reports of bystanders
stating opiate use.
Exam:
Vitals: HR 120, RR 16, O2 96%, BP 80/45,
T 98.0
Gen: Fully A&O, drowsy
CV: tachycardia
Pulm: CTAB
ABD: NT/ND
Neuro: CN II-XII intact, motor intact,
sensation intact, ambulates without difficulty to bathroom
My initial thought was that he may need
more naloxone or that he used a long acting
opiate. The tachycardia was a wild card didn’t fit the picture. He remained afebrile,
so I wasn’t thinking sepsis at that time. Due
to the tachycardia, I ordered labs (and a tox
screen for co-ingestants) and thought his
BP/HR would improve with fluids.
I reassessed him after liter #1 and #2 and
neither HR or BP improved. Labs returned
with an elevated WBC at 19.6. Opiates positive but tox screen otherwise negative. EKG:
sinus tachycardia. CXR and urine unremarkable. Even though I had no fever or
source I felt compelled to initiate a septic
workup: lactate returned at 7.9.
I was starting to get lost as why this guy
was so unresponsive to fluids and Dr. Dan
O’Brien and I brought the ultrasound to the
bedside. The patient was in acute systolic
failure with an ejection fraction of 10%. No
history of CHF and also no signs of volume
overload on exam except very mild pulmonary edema. Troponin peaked at 0.5.
He was admitted to Cardiology. He had
a cardiac cath on hospital day 3 with clean
coronary arteries. Ejection fraction improved to 60% by time of discharge. The
treating team today is still uncertain of the
cause.
These are two cases of sick patients being
in the holding area. Hopefully, it serves to
remind everyone that any patient can be
sick. .
Dr. Chris Kennedy is Chief Resident of Emergency Medicine at the University of Louisville
Hospital
SEPTEMBER 2016
31