Morning Report: 6/11/2012

A 25-year-old man was transported to the emergency department (ED) by police after exhibiting unusual behavior. The patient was found with marked agitation and altered mental status. His girlfriend reported that he had injected bath salts and was subsequently found running wildly throughout the local neighborhood, markedly combative and foaming at the mouth. On presentation to the ED, the patient was not verbal and was unable to provide additional history.

His initial examination revealed blood pressure 148/66 mm Hg, pulse rate 175 beats/min, respiratory rate 18 breaths/min, temperature
41.3°C (106.3°F) rectally, and transcutaneous oxygen
saturations 100%. The examination was significant for the

following: mydriasis, rightward deviation of the eyes, calor, and combativeness requiring restraint by multiple staff members. He received tracheal intubation after receiving midazolam 2 mg, etomidate 20 mg, and succinylcholine 120 mg. Cooling measures were initiated with the application of ice packs to the axilla and cooling blankets covering his body. After tracheal intubation and mechanical ventilation, sedation was maintained with a propofol infusion initially, followed by fentanyl and midazolam. During the ensuing hour, his temperature normalized and his blood pressure and pulse rate decreased.

Initial laboratory values were significant for the following: WBC count 17,000/mm3, potassium 5.1 mEq/L, serum bicarbonate
14 mEq/L, creatinine 2.88 mg/dL, glucose 45 mg/dL, aspartate aminotransferase 201 U/L, alanine aminotransferase 334 U/L, creatine kinase 2,334 U/L, troponin 3.24 ng/mL, and lactate 7 mg/dL. A urine drug screen result was positive only for benzodiazepines, which had been administered to the patient 90 minutes before the collection (initial screen result negative for marijuana, opiates, cocaine, barbiturates, amphetamines, and phencyclidine). A tricyclic antidepressant urine screen result was negative. Methanol, ethylene glycol, ethanol, salicylate, and acetaminophen were not detected in the blood. A head

computed tomography scan and spinal fluid result obtained by lumbar puncture were normal. The ECG result was significant only for sinus tachycardia.

The patient was admitted to the ICU. During the next 2 days, he developed renal failure, fulminant hepatic failure, disseminated intravascular coagulation, and rhabdomyolysis,

with peak laboratory values of aspartate aminotransferase 16,688 U/L, alanine aminotransferase 9,085 U/L, international normalized ratio greater than 9.3, platelets 16,000/_L (nadir), glucose 55 mg/dL (nadir), creatine kinase 235,377 U/L, creatinine 10.2 mg/dL, and troponin 29 ng/ mL. He remained critically ill and required continuous renal replacement therapy followed by hemodialysis because of anuric renal failure. He remained tracheally intubated, sedated, and unresponsive; intracranial pressure monitoring was initiated, which showed normal pressures. An initial echocardiogram revealed decreased global left ventricular systolic function, with an ejection fraction of 30%. He was extubated on hospital day 9, and his mental status normalized by hospital day 13. His transaminase levels,