Faculty Bibliography

Abstract Context. The optimal method of cooling hyperthermic patients is controversial. Although controlled data support ice water submersion, many authorities recommend a mist and fan technique. We report two patients with drug-induced hyperthermia, to demonstrate the rapid cooling rates of ice water submersion. Case details. Case 1. A 27-year-old man presented with a sympathomimetic toxic syndrome and a core temperature of 41.4 degrees C after ingesting 4-fluoroamphetamine. He was submerged in ice water and his core temperature fell to 38 degrees C within 18 minutes (a mean cooling rate of 0.18 degrees C/min). His vital signs stabilized, his mental status improved and he left on hospital day 2. Case 2. A 32-year-old man with a sympathomimetic toxic syndrome after cocaine use was transported in a body bag and arrived with a core temperature of 44.4 degrees C. He was intubated, sedated with IV benzodiazepines, and submerged in ice water. After 20 mins his temperature fell to 38.8 degrees C (a cooling rate of 0.28 degrees C/min). He was extubated the following day, and discharged on day 10. Discussion. In these two cases, cooling rates exceeded those reported for mist and fan technique. Since the priority in hyperthermia is rapid cooling, clinical data need to be collected to reaffirm the optimal approach.

Background : The NBOMes (N-Benzyl-Oxy-Methyl derivatives of known 2C phenylethylamines) are one of the newest classes of potent synthetic hallucinogens, described by EROWID as "the defining psychedelics of 2013." Despite schedule 1 status for three drugs in this class (25I-, 25C- and 25B-NBOMe), cases of NBOMe abuse by adolescents are reported to Poison Control Centers. We report the first case of 25C-NBOMe intoxication confirmed via mass spectrometry. Case Report : A 16-year-old girl with a history of bipolar disorder presented to the ED after having a witnessed seizure. Thirty minutes earlier, she self-administered "25I-NBOME" via blotter paper placed on her tongue. On examination, she was tachycardic with a heart rate of 146 beats/minute and increased muscle tone in both upper and lower extremities. She had altered mental status, garbled speech, and visual hallucinations, repeatedly stating, "LookEveryone is speaking Russian!" Within minutes of arrival, she had a second tonic-clonic seizure, which resolved after lorazepam 8 mg IV. The patient was admitted to the Pediatric ICU for further monitoring. Within 24 hours from exposure, her mental status had returned to baseline, but she complained of persistent stiffness in her arms and legs. On examination, she had increased rigidity in her bilateral thighs and 2 - 3 beats of ankle clonus bilaterally. Creatine phosphokinase (CPK) was elevated at 6042 units/ liter (u/L) on hospital day (HD) 1 and peaked by HD 3 at 47,906 u/L despite continuous IV fluids with sodium bicarbonate and diazepam IV. The patient's CPK level dropped transiently to 36,884 u/L and then again rose to 44,093 u/L on HD 5. She was discharged with a down-trending CPK on HD 8. A serum specimen obtained 7 hours post-admission and urine collected ~ 9 hours post-admission, analyzed by triple quadrapole mass spectrometry, contained 25CNBOMe present at > 0.025 nanograms/milliliter (ng/mL) and 1.0 ng/mL, respectively. Case Discussion : The NBOMes are sold in microgram doses on blotter !