A 22-year-old woman is brought to the emergency department by friends after passing out at a party. They report that alcohol and marijuana were available at the party but are not sure what the patient was using. The friends have seen her use cocaine and marijuana in the past. Bottles of prescription alprazolam and hydrocodone are found in her handbag. The patient has no known history of medical problems and there is no evidence of trauma. On examination, she is stuporous. Temperature is 36.1 C (97 F), blood pressure is 100/60 mm Hg, pulse is 54/min, and respirations are 6/min. The pupils are 3 mm and reactive. Heart and lung examination is normal and bowel sounds are present. On neurologic examination, the patient responds to painful stimuli and has decreased reflexes bilaterally. Administration of naloxone has no effect. Which of the following substances is the most likely cause of these findings?

Question

A 22-year-old woman is brought to the emergency department by friends after passing out at a party.  They report that alcohol and marijuana were available at the party but are not sure what the patient was using.  The friends have seen her use cocaine and marijuana in the past.  Bottles of prescription alprazolam and hydrocodone are found in her handbag.  The patient has no known history of medical problems and there is no evidence of trauma.  On examination, she is stuporous.  Temperature is 36.1 C (97 F), blood pressure is 100/60 mm Hg, pulse is 54/min, and respirations are 6/min.  The pupils are 3 mm and reactive.  Heart and lung examination is normal and bowel sounds are present.  On neurologic examination, the patient responds to painful stimuli and has decreased reflexes bilaterally.  Administration of naloxone has no effect.  Which of the following substances is the most likely cause of these findings?

Quizplus · Accepted Answer

This patient's presentation is consistent with a sedative-hypnotic overdose, most likely due to the combined effects of alcohol and benzodiazepines. An isolated overdose of benzodiazepines can cause altered level of consciousness, ataxia, and slurred speech but is unlikely to cause this degree of central nervous system depression. Most patients with isolated benzodiazepine overdose are arousable and have normal vital signs (Choice E). If signs such as bradycardia, hypotension, respiratory depression, and hyporeflexia are seen, as in this patient, co-ingestion of other sedative-hypnotics (the most common being alcohol) should be suspected. Opioid overdose can also result in altered consciousness and respiratory depression. However, this patient's failure to respond to the opioid antagonist naloxone, normal pupils, and presence of normal bowel sounds make opioid intoxication less likely (Choice D). (Choice B) Stimulants such as cocaine would typically cause increased arousal, agitation, dilated pupils, hyperthermia, tachycardia, hypertension, tachypnea, diaphoresis, and hyperreflexia; these are not present in this patient. (Choice C) Marijuana intoxication typically presents with tachycardia, increased respiratory rate, dry mouth, and conjunctival injection. Educational objective: Benzodiazepine overdose can result in altered mental status, ataxia, and slurred speech. When vital sign derangements or respiratory depression are seen, co-ingestion with other sedative-hypnotics/central nervous system depressants should be suspected. References: Polysubstance abuse: alcohol, opioids and benzodiazepines require coordinated engagement by society, patients, and physicians. (http://www.ncbi.nlm.nih.gov/pubmed/25671013) Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013. (http://www.ncbi.nlm.nih.gov/pubmed/26890165) A systematic review of research examining benzodiazepine-related mortality. (http://www.ncbi.nlm.nih.gov/pubmed/19125401)

A 22-Year-Old Woman Is Brought to the Emergency Department by Friends