ABIM - Poisoning Environmental Exposure - (Medicalstudyzone - Com)

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A 24-year-old man comes to the physician with cold extremities and loss of feeling in his hands. He is a
mountaineer who was on an expedition to climb Mt. Rainier. His group became lost in a storm and was
stranded at high altitude due to reduced visibility and high winds. The patient had several hours of
exposure to very low ambient temperatures before being rescued. He had on 2 pairs of gloves, including a
woolen inner pair and an outer shell. However, the outer shell was damaged during the climb.
Vital signs are within normal limits. Examination shows that the first through third digits are white, cold,
numb, and firm distal to the first Interphalangeal joint.
The fingers are immersed rapidly in water heated to 38 C (100.4 F). After 30 minutes, the fingers are
purplish-red between the proximal InterphaIangeaI and distal Interphalangealjoints.
Which of the following is the best next step in managing this patient?
A. Hyperbaric oxygen
B. Intravenous thrombolytic therapy
C. Nonadherent gauze dressings
D. Occlusive dressing
E. Prophylactic antibiotics
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A 24-year-old man comes to the physician with cold extremities and loss of feeling in his hands. He is a
mountaineer who was on an expedition to climb Mt. Rainier. His group became lost in a storm and was
stranded at high altitude due to reduced visibility and high winds. The patient had several hours of
exposure to very low ambient temperatures before being rescued. He had on 2 pairs of gloves, including a
woolen inner pair and an outer shell. However, the outer shell was damaged during the climb.
Vital signs are within normal limits. Examination shows that the first through third digits are white, cold,
numb, and firm distal to the first Interphalangeal joint.
The fingers are immersed rapidly in water heated to 38 C (100.4 F). After 30 minutes, the fingers are
purplish-red between the proximal InterphaIangeaI and distal Interphalangealjoints.
Which of the following is the best next step in managing this patient?
A. Hyperbaric oxygen [32%]
B. Intravenous thrombolytic therapy [7%]
C. Nonadherent gauze dressings [46%]
D. Occlusive dressing [3%]
E. Prophylactic antibiotics [8%]
Omitted
Correct answer
Ihi 46% 8 SecondS 04/24/2019
Answered correctly Time Spent Last Updated
C
Explanation
Frostbite is a severe and localized cold-induced injury most commonly affecting the ears, nose, cheeks,
chin, fingers, and toes. It is further classified as first degree (superficial localized pallor and surrounding
edema), second degree (large blisters that may form eschar), third degree (deeper and smaller
hemorrhagic blisters), and fourth degree (tissue necrosis extending to muscle and bone). Diagnosis is
usually clinical in susceptible individuals (eg, the homeless, mountaineers, soldiers, those stranded or
working in the cold). Technetium (Tc)-99 scintigraphy may predict long-term viability of affected tissue.
Treatment involves rapid rewarming with water heated to 37-39 C (98.6-102.2 F) (not hot) to reduce tissue
damage and analgesics (eg, opioids) for pain control.
After thawing is complete (usually in 15-30 minutes), localized tissue usually appears red or purple and is
soft to the touch. After rewarming, the affected areas are usually air dried and covered with a first layer of
nonadherent gauze using aseptic technique. Other treatment measures include tetanus prophylaxis,
possible splinting to prevent contractures, daily hydrotherapy, and elevation of the affected area (to reduce
edema). Severe frostbite may require early surgical consultation for possible tissue debridement,
escharotomy, or amputation.
(Choice A) There is insufficient data on whether hyperbaric oxygen therapy is useful in the treatment of
frostbite.
(Choice B) Limited evidence for thrombolytics suggests benefit in severe frostbite patients at high risk for
life-altering amputation (eg, multiple digits, proximal amputation) and who present < 24 hours from injury
without contraindications to tissue plasminogen activator use. However, clinicians must assess the
risk/benefit ratio for each patient.
(Choice D) Occlusive dressings may extend tissue damage and are usually avoided.
(Choice E) Prophylactic antibiotics are given only for signs of infection, which are not present in this
patient.
Educational objective:
Frostbite is a severe and localized cold-induced injury. It is best treated with rapid rewarming with water
temperatures of 37-39 C (98.6-102.2 F). After rewarming, the affected areas are usually air dried and
covered with nonadherent gauze. Daily hydrotherapy with subsequent dressing changes and elevation of
the affected area aid the healing of superficial frostbite.
References
• A clinical review of the management of frostbite.
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A 72-year-old man is scheduled for right knee replacement surgery due to severe osteoarthritis. He has no
other medical problems. He takes ibuprofen and occasionally oxycodone for knee pain. He also takes
herbal supplements that he purchases from a health food store.
Which of the following herbal supplements increases the risk of bleeding in this patient?
A. Echinacea
B. Ephedra
C. Ginkgo biloba
D. Kava
E. St John's wort
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<⅞ 2 of 2
A 72-year-old man is scheduled for right knee replacement surgery due to severe osteoarthritis. He has no
other medical problems. He takes ibuprofen and occasionally oxycodone for knee pain. He also takes
herbal supplements that he purchases from a health food store.
Which of the following herbal supplements increases the risk of bleeding in this patient?
A. Echinacea [7%]
B. Ephedra [2%]
C. Ginkgo biloba [47%]
D. Kava [9%]
E. St John's wort [33%]
Omitted
6 SecondS 06/28/2019
Correct answer
Answered correctly X—√ Time Spent Last Updated
C
Explanation
Herbal
Uses Side effects
supplement
Ginkgo biloba • Memory enhancement • Increased bleeding risk
Ginseng • Improved mental performance • Increased bleeding risk
• Mild stomach discomfort
Saw palmetto • Benign prostatic hyperplasia
• Increased bleeding risk
• Postmenopausal symptoms
Black cohosh • Hepatic injury
(hot flashes & vaginal dryness)
• Drug interactions: Antidepressants
• Depression (serotonin syndrome), OCs, anticoagulants
St John’s wort
• Insomnia (I INR), digoxin
• Hypertensive crisis
• Anxiety
Kava • Severe liver damage
• Insomnia
• Stomach ulcers • Hypertension
Licorice
• Bronchitis/viral infections • Hypokalemia
• Treatment & prevention of cold
Echinacea • Anaphylaxis (more likely in asthmatics)
& flu
• Hypertension
• Treatment of cold & flu
• Arrhythmia/MI/sudden death
Ephedra • Weight loss & improved
• Stroke
athletic performance
• Seizure
Ml = myocardial infarction; OCs = oral contraceptives.
This patient is scheduled for knee surgery and admits to use of herbal supplements. Many commonly used
herbs may interact with anticoagulants or increase the risk of bleeding (Table). It is generally
recommended that patients stop taking supplements known to affect hemostasis at least 14 days prior to
scheduled procedures. Ginkgo biloba, ginseng, and saw palmetto are associated with increased bleeding
risk and should be stopped before surgery or dental procedures.
(Choice A) Echinacea is used as an immune stimulant to protect against the common cold and flu.
Prolonged use of the supplement (> 10 days) is not recommended. It does not cause bleeding problems,
but some studies have shown anaphylaxis in patients with allergy/atopy.
(Choice B) Ephedrine was used in the early 1990s for weight loss, improving athletic performance, and
treating common colds. It is known to cause elevated blood pressure, fatal arrhythmias, and even sudden
death. The sale of ephedra-containing products is now illegal in the United States.
(Choice D) Kava is used as an anxiolytic and sedative and also to treat ADHD in children. There have
been several cases of severe Iivertoxicity, including cirrhosis and liver failure, associated with its use.
(Choice E) St John's wort has been used for centuries to treat depression. It may cause hypertension and
serotonin syndrome when used with antidepressants. It also decreases INR in patients on anticoagulants,
and thus drug levels may need close monitoring.
Herbal supplements are used frequently by the general population. Many such supplements (eg, ginkgo
biloba, ginseng, and saw palmetto) increase risk of bleeding and should be discontinued 14 days prior to
surgical procedures.
References
• Ginkgo biloba and cerebral bleeding: a case report and critical review.
• Intraoperative haemorrhage associated with the use of extract of saw palmetto herb: a case report and
review of literature.
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A 79-year-old man is found poorly responsive in his apartment by a neighbor in the middle of July. The
apartment is not air conditioned and the last few days have been extremely hot. The patient's neighbors
state that he lives alone and appeared fully functional in their interactions with him. No additional medical
history is available.
On physical examination, he appears Obtunded and responds slowly to commands. His temperature is
42.2o C (108o F), blood pressure is 90/60 mm Hg, pulse is 104∕min1 and respirations are 16∕min. The
patient's pulse oximetry shows 96% on room air. Mucous membranes are dry. His neck is supple, and
jugular veins are flat in the supine position. Cardiopulmonary examination is within normal limits. There
are no skin rashes. Deep tendon reflexes are 2+ and symmetrical. There is no muscular rigidity.
An electrocardiogram demonstrates sinus rhythm with nonspecific ST-segment changes. A chest film
shows no significant abnormalities. Laboratory workup is pending.
In addition to volume resuscitation, which of the following is the best initial therapy for this patient?
A. Alcohol sponge baths
B. Aspirin suppositories
C. Dantrolene
D. Evaporative cooling
E. Immersion in ice water
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A 79-year-old man is found poorly responsive in his apartment by a neighbor in the middle of July. The
apartment is not air conditioned and the last few days have been extremely hot. The patient's neighbors
state that he lives alone and appeared fully functional in their interactions with him. No additional medical
history is available.
On physical examination, he appears Obtunded and responds slowly to commands. His temperature is
42.2o C (108o F), blood pressure is 90/60 mm Hg, pulse is 104∕min1 and respirations are 16∕min. The
patient's pulse oximetry shows 96% on room air. Mucous membranes are dry. His neck is supple, and
jugular veins are flat in the supine position. Cardiopulmonary examination is within normal limits. There
are no skin rashes. Deep tendon reflexes are 2+ and symmetrical. There is no muscular rigidity.
An electrocardiogram demonstrates sinus rhythm with nonspecific ST-segment changes. A chest film
shows no significant abnormalities. Laboratory workup is pending.
In addition to volume resuscitation, which of the following is the best initial therapy for this patient?
A. Alcohol sponge baths [1%]
B. Aspirin suppositories [0%]
C. Dantrolene [2%]
D. Evaporative cooling [80%]
E. Immersion in ice water [14%]
Omitted
8 SecondS 02/14/2019
Correct answer
Answered correctly X—√ Time Spent Last Updated
D
Explanation
This patient's presentation is consistent with classic (nonexertional) heat stroke. Nonexertional heat stroke
is more common in the elderly and those with chronic medical conditions. Exertional heat stroke is more
common in young healthy athletes exercising heavily in high ambient temperature and humidity. Heat
stroke mortality is reported as 20%-60%.
Hyperthermia management includes supportive measures (eg, airway protection, circulatory support), rapid
evaporative cooling, cold IV normal saline boluses for hypotension or volume depletion, cooled oxygen and
blankets, and temperature monitoring via rectal or esophageal probes. Evaporated cooling is safe,
noninvasive, effective, and does not interfere with Othertreatment and monitoring. The technique involves
spraying mists of water with fans blowing air over moist skin.
Ice water immersion is also quick and effective in reducing the body temperature. However, it interferes
with monitoring and is associated with increased mortality in elderly patients with classic (nonexertional)
heat stroke. Younger patients with exertional heat stroke can better tolerate this technique (Choice E).
(Choice A) Alcohol sponge baths should be avoided because large amounts of alcohol may be absorbed
through dilated cutaneous blood vessels and lead to systemic toxicity.
(Choice B) Antipyretics (eg, acetaminophen, aspirin) are not helpful in heat stroke as the mechanism is
not regulated by the hypothalamus. Aspirin may even exacerbate complications such as renal failure or
disseminated intravascular coagulation.
(Choice C) Dantrolene is effective for treating hyperthermia associated with neuroleptic malignant
syndrome but is ineffective in other hyperthermic disorders. The absence of muscular rigidity makes
neuroleptic malignant syndrome unlikely.
Management of classic (nonexertional) heat stroke includes cooling methods (eg, evaporative cooling),
circulatory support (with intravenous fluid boluses), airway management, and treatment of complications.
Antipyretics and dantrolene are not useful in the management of heat stroke.
References
• Hot on the inside.
• Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external
cooling system.
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A 41-year-old man with a history of bipolar disorder is brought to the emergency department by his mother
for confusion and agitation that she noticed while visiting today. The patient denies suicidal ideation and
intentional overdose of his medication or illicit drugs. His only known medication is lithium.
His temperature is 37.2o C (99o F), blood pressure is 94/52 mm Hg, pulse is 89∕min, and respirations are
18∕min. The patient's pulse oximetry is 96% on room air. Examination shows dry mucous membranes,
clear lung fields, and normal first and second heart sounds. The patient has a flat affect and does not
answer most questions. He has a significant tremor in both hands.
Complete blood count
Hemoglobin 14.1 g/dL
Platelets 178,000∕μL
Leukocytes 13,400∕μL
Serum chemistry
Sodium 136 mEq/L
Potassium 4.2 mEq/L
Chloride 100 mEq/L
Bicarbonate 22 mEq/L
Blood urea nitrogen 94 mg/dL
Creatinine 4.4 mg/dL
Calcium 10 mg/dL
Glucose 92 mg/dL
4.2 mEq/L (normal 0.8 -
Lithium
1.2 mEq/L)
Electrocardiogram shows normal sinus rhythm. Intravenous fluids are initiated.

Which of the following is the most appropriate next step in management?
A. Activated charcoal
B. Forced diuresis
C. Hemodialysis
D. Ipecac
E. Whole-bowel irrigation
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A 41-year-old man with a history of bipolar disorder is brought to the emergency department by his mother
for confusion and agitation that she noticed while visiting today. The patient denies suicidal ideation and
intentional overdose of his medication or illicit drugs. His only known medication is lithium.
His temperature is 37.2o C (99o F), blood pressure is 94/52 mm Hg, pulse is 89∕min, and respirations are
18∕min. The patient's pulse oximetry is 96% on room air. Examination shows dry mucous membranes,
clear lung fields, and normal first and second heart sounds. The patient has a flat affect and does not
answer most questions. He has a significant tremor in both hands.
Complete blood count
Hemoglobin 14.1 g/dL
Platelets 178,000∕μL
Leukocytes 13,400∕μL
Serum chemistry
Sodium 136 mEq/L
Potassium 4.2 mEq/L
Chloride 100 mEq/L
Calcium 10 mg/dL
Glucose 92 mg/dL
4.2 mEq/L (normal 0.8 -
Lithium
1.2 mEq/L)
Electrocardiogram shows normal sinus rhythm. Intravenous fluids are initiated.

Which of the following is the most appropriate next step in management?
A. Activated charcoal [4%]
B. Forced diuresis [9%]
C. Hemodialysis [83%]
D. Ipecac [1%]
E. Whole-bowel irrigation [1%]
Omitted
Correct answer
Ihi 83% 31 SecondS 02/14/2019
Answered correctly Time Spent Last Updated
C
Explanation
This patient's presentation (sluggishness, confusion, agitation, and neuromuscular excitability with irregular,
coarse tremors) is consistent with acute-on-chronic lithium poisoning. Acute intoxication often presents
with nausea, vomiting, diarrhea, and late development of neurologic symptoms. Chronic lithium toxicity can
exhibit neurologic symptoms, but it usually occurs gradually over months or years. Patients taking chronic
lithium may also have signs of nephrogenic diabetes insipidus or thyroid dysfunction. Serum lithium levels
do not always correlate with signs of toxicity, especially in the acute setting.
Initial management includes evaluating and stabilizing the airway and circulation. Saline infusion is the
first-line therapy to ensure significant lithium clearance. Hemodialysis is indicated for serum lithium levels >
4 mEq/L (4 mmol∕L) OR levels > 2.5 r∩Eq∕L PLUS either signs of significant lithium toxicity (eg, seizures,
depressed mental status) or inability to excrete lithium (eg, renal disease, decompensated heart failure).
(Choice A) Activated charcoal is not indicated for lithium toxicity as it does not prevent lithium absorption
in the gastrointestinal tract.
(Choice B) Forced diuresis has little clinical effect and may predispose the patient to further volume
depletion.
(Choice D) Ipecac is not recommended as it can be effective in inducing vomiting but does not necessarily
ensure lithium removal.
(Choice E) Whole-bowel irrigation with polyethylene glycol may be given to awake and asymptomatic
patients within 2-3 hours of lithium consumption. Polyethylene glycol may be an alternate therapy to
hemodialysis in these patients as it can empty the bowel and decrease toxin absorption. However, it is not
beneficial for chronic toxicity.
Lithium toxicity should be managed initially by stabilizing the airway and circulation and aggressive saline
infusion to ensure significant lithium clearance. Hemodialysis is indicated for serum lithium levels > 4
mEq/L (4 mmol∕L) OR levels > 2.5 mEq/L PLUS either signs of significant lithium toxicity or inability to
excrete lithium.
References
• Preventing lithium intoxication. Guide for physicians.
• Toxicology in the ICU: part 1: general overview and approach to treatment.
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A 65-year-old woman comes to the emergency department due to 2 days of nausea and vomiting. Her
symptoms started a few hours after eating lunch, and she has since been unable to tolerate any oral
intake. The patient began to experience epigastric and retrosternal discomfort this morning, and she now
has pain in all her joints and muscles. Medical history includes hypertension; type 1 diabetes mellitus;
myocardial infarction 2 years ago that was treated with coronary stenting; and severe, degenerative lumbar
spinal stenosis. Medications include aspirin, atorvastatin, insulin, lisinopril, metoprolol, and morphine.
Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 94∕min, and respirations are
18∕min. The patient is awake and oriented to time, place, and person. Physical examination is significant
for diaphoresis and rhinorrhea. Abdominal examination is significant for epigastric tenderness and
hyperactive bowel sounds. ECG shows nonspecific ST-T changes. An older ECG is not available for
comparison.
Which of the following is the most likely cause of this patient's clinical presentation?
A. Acute pancreatitis
B. Hypoglycemia
C. Non-ST-elevation myocardial infarction
D. Opioid withdrawal
E. Worsening gastroenteritis
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A 65-year-old woman comes to the emergency department due to 2 days of nausea and vomiting. Her
symptoms started a few hours after eating lunch, and she has since been unable to tolerate any oral
intake. The patient began to experience epigastric and retrosternal discomfort this morning, and she now
has pain in all her joints and muscles. Medical history includes hypertension; type 1 diabetes mellitus;
myocardial infarction 2 years ago that was treated with coronary stenting; and severe, degenerative lumbar
spinal stenosis. Medications include aspirin, atorvastatin, insulin, lisinopril, metoprolol, and morphine.
Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 94∕min, and respirations are
18∕min. The patient is awake and oriented to time, place, and person. Physical examination is significant
for diaphoresis and rhinorrhea. Abdominal examination is significant for epigastric tenderness and
hyperactive bowel sounds. ECG shows nonspecific ST-T changes. An older ECG is not available for
comparison.
Which of the following is the most likely cause of this patient's clinical presentation?
A. Acute pancreatitis [7%]
B. Hypoglycemia [2%]
C. Non-ST-elevation myocardial infarction [7%]
<s D. Opioid withdrawal [77%]
E. Worsening gastroenteritis [5%]
Omitted
8 SecondS □ . 05/07/2019
Correct answer
Answered correctly Time Spent 44-1 Last Updated
D
Explanation
Clinical features of opioid withdrawal

• Acute opioid cessation/dose reduction after prolonged use
• Gastrointestinal: nausea, vomiting, diarrhea, cramping, ↑ bowel sounds
Clinical
• Cardiac:f pulse, ↑ blood pressure, diaphoresis
presentation
• Psychological: insomnia, yawning, dysphoric mood
• Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis
• Opioid agonist: methadone (preferred) or buprenorphine
Management • Nonopioid: Clonidine or adjunctive medications (antiemetics, antidiarrheals,
benzodiazepines)
This patient likely contracted a foodborne illness after eating lunch. The resultant nausea and vomiting left
her unable to tolerate oral intake, causing abrupt cessation of her oral morphine. The development of
abdominal cramping, arthralgias, myalgias, diaphoresis, and rhinorrhea 2 days later (when symptoms of
acute gastroenteritis should be diminishing) is most likely due to opioid withdrawal.
Tolerance to opioids, a prerequisite for withdrawal, generally develops after ≥3 weeks of regular use.
Opioid withdrawal typically begins within 3 half-lives Ofabrupt discontinuation (ie, within 6-12 hours in the
case of short-acting morphine; 24-48 hours for long-acting) in patients with prolonged use. Symptoms
typically peak within 3 days of last use and may persist for up to 10 days.
(Choice A) Although acute pancreatitis may present with nausea, vomiting, and mid-epigastric abdominal
pain that radiates to the back, it is rarely associated with diffuse joint and muscle pain. Given the abrupt
cessation of morphine, opioid withdrawal better explains the patient's condition.
(Choice B) Hypoglycemia may be associated with palpitations, diaphoresis, and anxiety. Hypoglycemia
would not explain this patient's presentation.
(Choice C) Non-ST-elevation myocardial infarction (Ml) can present with chest pain, gastrointestinal
symptoms (eg, abdominal pain, nausea, vomiting), and diaphoresis. Although this patient has a history of
recent Ml and may warrant further evaluation (eg, serial troponins), her overall clinical picture and history of
opioid use are more consistent with opioid withdrawal.
(Choice E) The rapid onset of gastrointestinal symptoms after eating lunch (ie, <6 hours) points to a
foodborne, preformed toxin as the cause of this patient's gastroenteritis. However, foodborne illness
caused by a preformed toxin rarely persists for >2-3 days, typically peaks in severity within this timeframe,
and is rarely associated with diffuse joint and muscle pain.
Symptoms of opioid withdrawal generally begin within 1-2 days after abrupt opioid cessation in patients
with sustained use (ie, ≥3 weeks). Clinical features include gastrointestinal symptoms (eg, persistent
nausea/vomiting), rhinorrhea or lacrimation, diaphoresis, arthralgias, myalgias, mydriasis, and cardiac
symptoms (eg, tachycardia).
References
• Opioid withdrawal syndrome: emerging concepts and novel therapeutic targets.
• Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for
everyday practice.
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A 20-year-old woman is brought to the emergency department from a college dorm. She attended a party
earlier that night and was brought back to her room by her roommate. The roommate told paramedics that
she called for an ambulance because the patient was agitated, combative, and "confused," and then
appeared to have a seizure. The patient was Obtunded by the time the paramedics arrived. She has a
history of psychosis and takes risperidone and diphenhydramine nightly.
Temperature is 39.4 C (103 F), blood pressure is 179/108 mm Hg, pulse is 135/min, and respirations are
24∕min. Physical examination shows a young diaphoretic woman who is warm to the touch. Pupils are
dilated. There is no nystagmus. Occasional tremors are noted. She is hyperreflexic.
Laboratory results are as follows:
Serum chemistry
Sodium 116 mEq/L
Aspartate aminotransferase (SGOT) 406 U/L

Alanine aminotransferase (SGPT) 314 U/L
International normalized ratio (INR) 4.5
Creatine kinase, serum 22,656 U/L
Which of the following is the most likely ingestion causing this patient's findings?
A. 3,4-methylenedioxymethamphetamine
B. Diphenhydramine
C. Phencyclidine
D. Psilocybin
E. Risperidone
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A 20-year-old woman is brought to the emergency department from a college dorm. She attended a party
earlier that night and was brought back to her room by her roommate. The roommate told paramedics that
she called for an ambulance because the patient was agitated, combative, and "confused," and then
appeared to have a seizure. The patient was Obtunded by the time the paramedics arrived. She has a
history of psychosis and takes risperidone and diphenhydramine nightly.
Temperature is 39.4 C (103 F), blood pressure is 179/108 mm Hg, pulse is 135/min, and respirations are
24∕min. Physical examination shows a young diaphoretic woman who is warm to the touch. Pupils are
dilated. There is no nystagmus. Occasional tremors are noted. She is hyperreflexic.
Laboratory results are as follows:
Serum chemistry
Sodium 116 mEq/L
Aspartate aminotransferase (SGOT) 406 U/L

Alanine aminotransferase (SGPT) 314 U/L
International normalized ratio (INR) 4.5
Creatine kinase, serum 22,656 U/L
Which of the following is the most likely ingestion causing this patient's findings?
A. 3,4-methylenedioxymethamphetamine [57%]
B. Diphenhydramine [3%]
C. Phencyclidine [23%]
D. Psilocybin [3%]
E. Risperidone [11 %]
Omitted
Correct answer
Ihi 57% IOSecondS 01/14/2019
Answered correctly Z Time Spent Last Updated
A
Explanation
3,4-methylenedioxymethamphetamine (MDMA, ecstasy, Molly) is the most common stimulant used in

dance clubs and raves. The ingestion of MDMA increases release of serotonin, dopamine, and
norepinephrine from presynaptic neurons, preventing their metabolism by inhibiting monoamine oxidase.
An oral dose can cause symptoms within 30-60 minutes and last up to 8 hours. Symptoms include
euphoria with a sense of profound insight, intimacy, and well-being, but agitation and combativeness can
also be present. Adverse effects resulting from sympathetic overload include tachycardia, mydriasis,
diaphoresis, tremor, hypertension, arrhythmias, and urinary retention.
Serotonin syndrome secondary to MDMA presents with delirium, hyperthermia, autonomic instability,
and neuromuscular irritability. It may result in end-organ damage, rhabdomyolysis with acute renal
failure, hepatic failure, acute respiratory distress syndrome, and coagulopathy from disseminated
intravascular coagulation. Heat from the exertion of dancing in a crowded room coupled with the MDMA-
induced hyperthermia can easily lead to excessive water intake and severe hyponatremia. Neurologic
effects include confusion, agitation, and seizures due to both MDMA and hyponatremia. Treatment
includes supportive care, benzodiazepines (for hypertension, seizures, and agitation), fluids for
hyponatremia, and ice baths for hyperthermia.
(Choice B) Diphenhydramine overdose usually presents with anticholinergic overdose symptoms such as
flushing (red as a beet), very dry skin without diaphoresis (dry as a bone), mydriasis (blind as a bat),
agitation (mad as a hatter), and fever (hot as a hare). Sedation can also occur due to antihistaminic effect.
MDMA toxicity causes diaphoresis instead of dry skin.
(Choice C) Phencyclidine (PCP) intoxication may present with bizarre or violent behavior, psychomotor
agitation, hallucinations, and incoordination. However, seizures (and rhabdomyolysis) are less common.
PCP intoxication often presents with nystagmus (horizontal and vertical), which is not present in this
patient.
(Choice D) The ingestion of psilocybin (a hallucinogen found in certain mushrooms) can be associated
with serotonergic effects. However, physical symptoms are usually mild. Significant sympathetic activation
and seizures occur much less commonly with psilocybin.
(Choice E) Risperidone overdose would likely cause muscle stiffness and/or oversedation. Neuroleptic
malignant syndrome, which can occur at any antipsychotic dose, is characterized by mental status
changes, severe hyperthermia (temperatures sometimes >40 C [104 F]), and generalized lead-pipe rigidity
(rather than hyperreflexia).
MDMA (3,4-methylenedioxymethamphetamine) is a stimulant used commonly at parties with overdose
presenting as serotonin syndrome, severe hyperthermia, and hyponatremia. MDMA overdose can lead to
seizures, coagulopathy, and renal and hepatic failure.
References
• How MDMA’s pharmacology and pharmacokinetics drive desired effects and harms.
• Hallucinogen use disorders.
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Electrocardiogram shows normal sinus rhythm. Intravenous fluids are initiated.

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Clinical features of opioid withdrawal

Aspartate aminotransferase (SGOT) 406 U/L

Aspartate aminotransferase (SGOT) 406 U/L

3,4-methylenedioxymethamphetamine (MDMA, ecstasy, Molly) is the most common stimulant used in

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