A 46-year-old man is brought from jail to the emergency department after a suicide attempt. The patient was arrested earlier today for possession of drugs and shortly afterward was found trying to strangle himself with a shoelace. He was unconscious for a few seconds until the shoelace was cut from his neck. On arrival, the patient is alert and fully oriented. Vital signs are within normal limits. Physical examination shows ligature marks on the neck but is otherwise normal. Urine drug screening is positive for cocaine and opiates. CT scan of the head and neck reveals no abnormalities. The patient is admitted for psychiatric treatment. A few hours later, he becomes restless and anxious and reports feeling nauseous. Temperature is 37.7 C (99.9 F), blood pressure is 138/90 mm Hg, and pulse is 100/min. The patient appears flushed and diaphoretic. Heart and lung sounds are normal. Physical examination shows no other abnormalities. ECG demonstrates sinus tachycardia. Complete blood count and comprehensive metabolic panel are normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 46-year-old man is brought from jail to the emergency department after a suicide attempt.  The patient was arrested earlier today for possession of drugs and shortly afterward was found trying to strangle himself with a shoelace.  He was unconscious for a few seconds until the shoelace was cut from his neck.  On arrival, the patient is alert and fully oriented.  Vital signs are within normal limits.  Physical examination shows ligature marks on the neck but is otherwise normal.  Urine drug screening is positive for cocaine and opiates.  CT scan of the head and neck reveals no abnormalities.  The patient is admitted for psychiatric treatment.  A few hours later, he becomes restless and anxious and reports feeling nauseous.  Temperature is 37.7 C (99.9 F), blood pressure is 138/90 mm Hg, and pulse is 100/min.  The patient appears flushed and diaphoretic.  Heart and lung sounds are normal.  Physical examination shows no other abnormalities.  ECG demonstrates sinus tachycardia.  Complete blood count and comprehensive metabolic panel are normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7da_f2c3_bc81_1b2d23602348_MD0003_00 The acute onset of nausea, restlessness/anxiety, diaphoresis, tachycardia, and elevated blood pressure several hours after admission of a patient with a urine drug screen positive for opiates is most likely due to opioid withdrawal. Patients with opioid dependence typically develop withdrawal symptoms within 6-12 hours of the last dose. Other symptoms include vomiting, cramping, diarrhea, rhinorrhea, lacrimation, yawning, arthralgias, and myalgias. Physical examination may show tachycardia, hypertension, and diaphoresis in addition to mydriasis, piloerection, and hyperactive bowel sounds. Treatment options for acute opioid withdrawal include administration of opioid agonists (eg, low-dose methadone, buprenorphine) and/or nonopioid medications. Clonidine, a central alpha-2 adrenergic agonist, is effective in blunting withdrawal symptoms by reducing noradrenergic hyperactivity. Clonidine would be particularly helpful in decreasing autonomic symptoms (ie, diaphoresis, nausea, anxiety, tachycardia, hypertension) in this patient. Adverse effects may include hypotension and sedation. Alpha-2 adrenergic agonists are also frequently used as adjuncts for the treatment of opioid withdrawal with methadone or buprenorphine. (Choice A) Beta-adrenergic antagonists such as metoprolol do not inhibit the central release of norepinephrine, the primary cause of opioid withdrawal symptoms. They are not indicated in the treatment of cardiovascular complications of opioid withdrawal. (Choices B and C) Blood cultures and a chest x-ray would not be indicated in this patient who has no findings suggestive of an infectious process (no fever, no leukocytosis) or cardiopulmonary abnormalities (normal heart and lung examination, ECG with sinus tachycardia but no ischemic changes). The presence of normal vital signs on arrival in the emergency department and the development of signs of autonomic hyperactivity several hours later are more suggestive of a withdrawal process. (Choice E) Administering the opioid antagonist naltrexone would worsen the patient's withdrawal symptoms. Naltrexone is an option for maintenance treatment to prevent relapse in opioid use disorder but should not be used prior to completion of a medically supervised withdrawal. Educational objective: Opioid withdrawal should be suspected in a patient who uses opioids and develops signs of noradrenergic hyperactivity within hours of admission. Clonidine, a central alpha-2 adrenergic agonist, is effective in decreasing the autonomic symptoms associated with opioid withdrawal. References: Alpha2-adrenergic agonists for the management of opioid withdrawal. (http://www.ncbi.nlm.nih.gov/pubmed/27140827)

A 46-Year-Old Man Is Brought from Jail to the Emergency