Altered Consciousness

SPEAKER_00 0:11

Hello and welcome to the Home of Medicine podcast with me, Dr. Amy Burberidge.

SPEAKER_01 0:16

And me, Dr. Ben Lovell. Hi, Amy.

SPEAKER_00 0:18

Hello. So, Ben, I have a very interesting case for you, and I also think it's a little bit different as well. Okay. So intriguing, but also I think it's a case that really challenges me. But I think it's right up your street.

SPEAKER_01 0:37

So Oh, okay. Sounds like it might really challenge me. But you know what I like to challenge? That's okay. Exactly.

SPEAKER_00 0:42

Okay. So this is a case I saw actually quite quite a little while ago now. But it really sticks in my head. And it was actually a patient I saw when I was a registrar, so it was a very long time ago. But I'm gonna start, and it's a 47-year-old man. And you're called to the Resus Department in the A E because you have a patient with a decreased GCS, and AE are a bit stuck. So they call the Med Reg for some support. Okay. You rock up. The story from the emergency department is that this gentleman was found unconscious in the street, sort of slumped over to one side. He was alone and doesn't appear to have any identifiable information on him. So no phone, no wallets, no driving license, nothing like this. So you've basically got uh Mr. X in AE Resus. ED want a little bit of support for this patient with a decreased GCS. What do you do?

SPEAKER_01 1:58

Okay, I go, first of all. You're right, this is right up my street. I love a possibility. I love a sixth patient. I love Resus. I love hanging out in Resus. All the really fun stuff happens there. So I'm walking to Resus on the way, I'm thinking, um, what are my heuristics? What are my shortcuts? What caused low GCS? Something's happened inside his head. So have we scanned his brain for something like a hemorrhage? Or something's happened metabolically. So is this having a massive hypo? Have we done a blood sugar? Or is this toxicity? Has he taken something that has uh depressed his conscious level? Has he got pinpoint pupils because there's opiates on board, or are there benzos on board? I'm thinking about science for that as well. And there's probably main three differentials, I would say, in a 47, which is still, by the way, a very young patient.

SPEAKER_00 2:46

Very young, very, very young.

SPEAKER_01 2:48

Very young. I spring chicken at the patient from it. You wouldn't see things like profound hypoactive delirium due to sepsis in someone usually of that age group. So those are my number one things I'm thinking about on the way there, going. Is there trauma and have we scanned the brain? Have we checked him for metabolic disturbances? Primarily hypoglycemia is a big one I think of. Or has there something been ingested? Um, do we have any clues? I'm also thinking it's unusual that he's been found without anything on him. I don't go out the house without my phone. I don't know anybody else who does, but you know, I guess you're allowed to pop out. Not everybody's like me. You're allowed to go out without your phone and become ill. Um and I don't actually take my ID with me wherever I go. I don't carry my wallet with my uh credit cards in because I've got everything on my phone. So yeah, I'm not going to draw too many assumptions from the fact he's got no ID on him at the moment. I'm more interested in the puzzle of the GCS. So I'm excited to meet him.

SPEAKER_00 3:44

Okay, so you turn up, and um there's a few doctors around, a few nurses around, and they're not sure what to do. They've stabilised the gentleman. So they've gone through A, B, C, D, E. But actually, the reason they want a medic there is to try and identify the cause of why this gentleman is unconscious and has a low GCS. Now you said trauma. Now they've scanned his head.

SPEAKER_01 4:12

Okay.

SPEAKER_00 4:13

CT head was normal. So there was no hemorrhage, there was no infarct that was seen on the CT. They are considering doing an MRI, although given its age. Yeah, exactly. It takes time. So they're thinking maybe this is sort of a non-trauma cause of collapse rather than a trauma cause of collapse. So what do you want to do? You rock up and you're in recus. What's your first thing to do?

SPEAKER_01 4:41

First thing is I go to the patient with an inquiring mind. Um, everybody, please keep calm. I don't like shouting. I don't like I don't have a lot of activity at the bedside, but I'm trying to think. So I'm gonna go there very calmly and I'm gonna do my A to E assessment. And A, I really want to get that done as soon as possible. I don't know how low this man's GCS is, but the first thing I'm gonna worry about is is he maintaining an airway? When your GCS drops below sort of eight, seven-ish, eight-ish. This is not a hard cut-off cutoff, by the way, just a vague rule of thumb. You do start to relax the muscles, which maintain an airway, your tongue falls back, your secretions gather, and that's when you start choking and we write about asphyxiation. So I'm gonna go straight to the bedside. I'm gonna give him a good shake and a shout just to make sure he's not suddenly gonna wake up and go, what? Um, and I'm gonna assess his airway first of all. Is it patent? Have we put anything in to keep it open, or is he maintaining his own airway? That's crucially important. That's gonna take about five seconds for me to evaluate. If I had any concerns about his airway, such as noisy breathing or very difficult work of breathing, then something we might think about isn't is there something to open his airway, such as a Gadell or a nasopharyngeal tube? Then I'm gonna swiftly move on to B, and that's gonna involve me very quickly looking at his saturations. If a chest x-ray has been done, I'll have a peek at that as well. Uh and maybe I might even dust off the stethoscope and just make sure he's got equal air entry. That won't take me more than 20 seconds to do. Rapidly moving on to C. What's his heart rate and what's his blood pressure? And do either of those two parameters need addressing urgently or correcting? Um, hold his hand, I will feel peripheries, feel pulses, uh, and get a sort of sense if I can about fluid status as well. That's gonna take me 20 seconds, then I can move on to D. Calculate his GCS, what's the score for eyes, what's the score for voice, what's the score for motor, what's the total score? That's gonna prompt me to think: do we need to get an anesthetist down here pretty quickly? Because the airway might go. Uh, even though we don't know what the cause is yet of his decreased consciousness, we're still allowed to call the airway doctors in an emergency and say, can you come and support an airway apart? We're all scratching our beards and having a think. And then I want to get part of D. I always stick my glucose in D. So I want to get that glucose level. And then E, we better have a proper good look at this patient because it's a bit of a man of mystery that's gonna pull the sheets down, have a look at his tummy, have a look around him. He's not bleeding anywhere, he hasn't got a massive swollen calf because of a DVT. They've done a great big ulcerating infected wound on the back of a leg or an incarcerated hernia somewhere or something like that. I reckon I can do that A to E assessment easily within 90 seconds.

SPEAKER_00 7:18

Wow.

SPEAKER_01 7:19

Give me a lot of information I need, and I can correct as I go.

SPEAKER_00 7:24

Okay, shall I tell you his A to E assessment?

SPEAKER_01 7:27

Yep.

SPEAKER_00 7:28

Okay, so when you arrive in Rhesus, you're doing your rapidly quick um A to E, which is amazing. So, first of all, his airway is patent actually, and you can't hear any upper airway secretions. There's no airway adjuncts inside you at the moment. And actually, his oxygen saturations are 89% on room air.

SPEAKER_01 7:48

That's too low. Okay, yep.

SPEAKER_00 7:50

Okay, what are you gonna do with that then?

SPEAKER_01 7:53

Put oxygen on. I think it's a reasonable thing to do. We worry about um retention and let's see up the narcosis very reasonably, but you look at any guideline, you have a critically unwell patient, you put the oxygen on, and then you just then you look and see whether or not that was the right thing to do. So, in the in terms of someone who's got a decreased conscious level and is hypoxic, I would say, could you put the 15 liters non-rebreating mask on now? I'll probably do an ABG pretty soon to make sure he hasn't got profound type 2 respiratory failure, which well then I'll correct with any we'll talk about how I might correct that. But I think a hypoxic sick person gets some oxygen.

SPEAKER_00 8:26

Okay. Heart rate 128. Bit quick, okay. Regular? Regular.

SPEAKER_01 8:33

Sinus, yep, okay.

SPEAKER_00 8:35

Blood pressure 165 over 95.

SPEAKER_01 8:39

I'm happy with that. Yeah. How are you? Well, it's a bit high, isn't it? But at least he's gonna be perfusing his organs. Um okay. Yep. I won't I worry more about if it was 65 over something and he and that would say, oh, maybe he's not perfusing his brain, and that's why he won't wake up. But 165 over 95, all his organs are gonna get um the blood that they need for now. So I'm uh whilst it is high, I I'm not too worried about that at the moment.

SPEAKER_00 9:04

Okay. Respirate of 10.

SPEAKER_01 9:06

That's way too low. Okay.

SPEAKER_00 9:08

Temperature 38.2.

SPEAKER_01 9:11

A bit febrile. Okay.

SPEAKER_00 9:14

And you wanted his glucose as well, you said.

SPEAKER_01 9:16

Yeah, let's move on to D. So glucose.

SPEAKER_00 9:18

18.

SPEAKER_01 9:20

Okay, high. That's high. That's that's not physiological. That is high. So I wonder if this is a diabetic man, but it's not hypoglycemic, and this should not be causing neuroglycopenia, which would cause a low conscious level.

SPEAKER_00 9:30

Okay.

SPEAKER_01 9:30

And then pupils, yeah.

SPEAKER_00 9:33

Dilated.

SPEAKER_01 9:35

Right. So not pinpoint. So there goes my opiate toxicity theory, but that's great. Yep. And is GCS?

SPEAKER_00 9:42

So is GCS. Now, I'm gonna admit something here, Ben. I really struggle with measuring GCS.

SPEAKER_01 9:50

But you can't remember the parameters and what's I I never remember them.

SPEAKER_00 9:55

Nobody does. Really? Yeah, we all got it. Okay, okay. We have Ken Murray. Okay. So he's not spontaneously opening his eyes. There is groaning. Um, but there's no, you can't really understand what he's saying. And movement-wise, he's there's a little bit of sort of thrashing about of the arms and the legs.

SPEAKER_01 10:19

Spontaneous. Spontaneous movement but not following commands, not spontaneous. No, when I ask him.

SPEAKER_00 10:25

No.

SPEAKER_01 10:26

All right. So uh let's call that eyes. Did you say it didn't open at all?

SPEAKER_00 10:30

Or did they're opening, yeah. Yeah.

SPEAKER_01 10:33

So i's is four. V is groaning but no recognizable sounds. No. So that's a four or a five uh four, probably, and movement was spontaneous but not following commands. Exactly. So it's only actually about 13-ish, which is not as bad. Okay, as as it could be, yes.

SPEAKER_00 10:51

No, that's true.

SPEAKER_01 10:54

Okay. Um, let's move on to E, please.

SPEAKER_00 10:58

Okay, so E, you examine him and he's incredibly sweaty.

SPEAKER_01 11:04

Yeah.

SPEAKER_00 11:04

He looks pretty unkempt.

SPEAKER_01 11:08

Okay.

SPEAKER_00 11:09

He's a little bit smelly. So he looks like he may not have washed for a little while.

SPEAKER_01 11:15

Malodorous.

SPEAKER_00 11:16

Malodorous, we would say. Although, to be fair, after Day and Amy, I'm probably malodorous.

SPEAKER_01 11:21

Maybe you were smelling yourself.

SPEAKER_00 11:22

Yeah, okay. Sometimes I do that and I'm like, oh, it's me, not um, and his clothes look like they haven't been washed for quite a long time.

SPEAKER_01 11:33

Okay. Maybe this is a man who with no fixed abode.

SPEAKER_00 11:36

Yes. And that's the sort of thought process that was going on in my mind. Actually, was he found on the street because actually he has no fixed abode and he's homeless potentially? Or has he just had, I don't know, just not had a shower for a long time. And that can sometimes happen as well. So that was where my thought process was going. But on the rest of the examination, there was nothing. You mentioned ulcers, there were no ulcers noted, cars were soft and non-tender.

SPEAKER_02 12:06

Yeah.

SPEAKER_00 12:07

There was some random bruises on this gentleman's legs, on his arms and his chest, but nothing significant. Heart sounds were normal, chest was clear, abdomen was soft and non-tender.

SPEAKER_01 12:24

Um, no injection marks anywhere implying intravenous drug use?

SPEAKER_00 12:29

Not that were obvious.

SPEAKER_01 12:32

Okay. Um, and you said heart sounds were normal, no split hemorrhages on the nails.

SPEAKER_00 12:37

Yeah.

SPEAKER_01 12:38

No.

SPEAKER_00 12:39

To be fair at the time, because he was he was very unkempt and quite dirty. There was a lot of dirt down the nails, and um the hands were and the feet were very dirty. And I always think you can tell a huge amount about a person, I've said this many times, from looking at their fingernails and looking at their toenails. Um, and they, yeah, so couldn't really see any spinter hemorrhages, but was obvious that this gentleman wasn't really looking after himself very well.

SPEAKER_01 13:07

Okay. So let me see who I can tie this together.

SPEAKER_00 13:10

Okay.

SPEAKER_01 13:11

Um, the hypoxia and the low respiratory rate, that demands a blood gas. I'm worried about him hypoventilating, and that means he will be building up CO2, which could be contributing, maybe in part, if not wholly contributing to his um decreased GCS. So he definitely needs an ABG. That ABG would also give me some useful information, for example, with regards to lactate.

SPEAKER_02 13:36

Yeah.

SPEAKER_01 13:36

Um, it would also, if it showed a metabolic acidosis, that might tie in with my next um requested test, which would be for a point of care ketones. If this man has got a CBG of 18, could there be an element of early DKA? It's not very high, but if he's a diabetic, um ketoneemic, that would show up on the gas as well. So I'd like the ketones as well as the ABG. Uh and as a side note, it is very, very difficult to be an insulin-dependent diabetic if you're unhoused because you just have nowhere to you have no fridge to put your insulin in, and you can't store your needles cleanly. So they really, really struggle. Um now look, he's febrile as well. Now, this could be infective um your central nervous system infection, such as encephalitis. That's one thing I'm thinking about now. He's in addition to any infection in addition to something else what's going on. The other thing I'm thinking about is is his GCS low because he's post-ictal? Did he fit? Because you do get a SERS, um, an inflammatory response, and a and a temperature spike after you have a grammar seizure. So the only other thing I'd be thinking about looking at him, are there any subtle signs of ongoing epileptic activities such as eye flickering or semi-purposeful hand movement? Or is it lactate 17? Anything else that I could point towards? Maybe did this man have an unwitnessed seizure in the street and has now been found in a profound post-tical state, leading to hypoventilation and a temperature spike? That might tie a few things together neatly. The last thing to mention is the dilated pupils. Now this goes against opiates, but it could be a toxydrome. So I'm thinking um high temperature, I'm thinking dilated pupils, very sweaty, hypertensive, tachycardic. Has he got either um a toxidrome, a sympathetic toxidrome? Has he something that stimulated a sympathetic nervous system and dilated his pupils and made him tacky? Um they tend to be agitated rather than rather than sleepy, unless it's like the very late stage. Um cocaine, amphetamines, things like that. Um anticholinergic toxydromes would give you a dilated pupil. What on earth would they have had that would cause that? An antihistamine overdose, a tricyclic overdose would cause that. Um all right, let's make a shopping list. I'd like, please, an ABG. I'd like his full set of blood stand, please. Let's do some whilst we're bleeding him because he is febrile. Okay. And after I've got the information, I'm going to take a view about how I'm going to resuscitate him.

SPEAKER_00 16:14

Okay. Would you give antibiotics at this point?

SPEAKER_01 16:17

Um, not yet. Does it trigger for sepsis? No, I can see my air quotes. Trigger for sepsis. Fever, tachycardia. Potentially, yes. To be honest, I'd be surprised if ED hadn't already given him some etheroxine now, which I think is very reasonable. But at the moment, we have time. Um do we? I want I want the lactate and I want to have another little think. My threshold for giving antibiotics is super low, so I will give them very easy without any panic or cause. But I want those tests first. I want to review those results first.

SPEAKER_00 16:51

Okay. Lactate, six.

SPEAKER_01 16:54

That's too high. Okay.

SPEAKER_00 16:56

You mentioned ketones.

SPEAKER_01 16:58

Yeah.

SPEAKER_00 16:58

1.4.

SPEAKER_01 17:00

That's high. Okay.

SPEAKER_00 17:02

CO2?

SPEAKER_01 17:03

Yeah.

SPEAKER_00 17:04

Six.

SPEAKER_01 17:05

That's upper limit normal. Okay. And his um other param parameters on the ABG? His uh PO2?

SPEAKER_00 17:14

PO2 is well, is now on 15 litres of oxygen and it's 15. Okay, that's low.

SPEAKER_01 17:21

Some of it's 15 litres of oxygen. You'd expect their uh PO2 to be something like in the 60s or something like that. Um so there is a there is a VQ mismatch there, right? Okay.

SPEAKER_00 17:32

And pH is yeah, 7.37.

SPEAKER_01 17:38

Normal values. Bicarb?

SPEAKER_00 17:40

Bicarb. I haven't I didn't write that down.

SPEAKER_01 17:44

Probably because it wasn't abnormal or important then. Maybe one of the scenes right. This is getting really interesting. So let me see if I have my pen and paper out now. So on one hand, we have a gentleman who's febrile, tachycardic, and a lactate of six. Fine, you've convinced me. Let's treat for sepsis. So I'd like 1.5 grams of IV kepheroxine, please, as broad spectrum antibiotic. That's my local protocol for infection.

SPEAKER_00 18:11

You mentioned encephalitis.

SPEAKER_01 18:13

Yeah.

SPEAKER_00 18:14

Would you give acyclovia?

SPEAKER_01 18:16

I'm still thinking. I'm still thinking.

SPEAKER_00 18:17

Okay, sorry, sorry.

SPEAKER_01 18:19

So IV kef, that's going in, please. 1.5 da da da da da. All right, what else I want to give straight away? Um, he's ketonemic and he's hyperglycemic, but I need to clear his ketones. So I'm thinking about a variable rate insulin infusion, what we used to call a sliding scale, or even a fixed rate actually, to clear the ketones. I think I might do that actually. Let's start a fixed-rate insulin infusion to target his glucose levels to um be between 7 and 12. Um, and when they get to that level, we can add in some dextrose to avoid hypoglycemia, but let's clear his ketones. Um, I didn't have his blood results yet. Does he have a sodium and his user knees and things like that, please?

SPEAKER_00 19:02

Yeah, absolutely. So his sodium is 148.

SPEAKER_01 19:08

Just above normal, okay.

SPEAKER_00 19:09

Yeah. Uh he's got a potassium of 4.1.

SPEAKER_01 19:13

Normal.

SPEAKER_00 19:14

He's got a urea of 19. High. And a creatinine of 232.

SPEAKER_01 19:20

Okay, so that's a kidney impairment. We don't know his previous results, so we can't know if it's AKI or this his usual renal function. On the side of safety, this is an AKI.

SPEAKER_00 19:30

All right. Hemoglobin is 120.

SPEAKER_01 19:34

120.

SPEAKER_00 19:34

Yeah. White cell count is 14.2.

SPEAKER_01 19:38

Yeah.

SPEAKER_00 19:39

Neutrophils 10.4.

SPEAKER_01 19:42

Okay.

SPEAKER_00 19:42

CRP? 76.

SPEAKER_01 19:45

Okay. All right. So we're going to treat the sepsis. So I've said that. IVK. Okay. We're going to try and get his um insulin and his ketones into normal parameters with an insulin infusion. So get his um his breathing and his ventilation. He's got type one respiratory failure. Um, and he's not retaining C. I mean, six is the upper limit of normal for CO2, but I think we can go up with the insulin, with the oxygen a little bit, um, and targets that sort of 94 to 98. We've got no indication that we shouldn't do that. Um, so O2 goes there. Let's do the full sepsis six and give them some IV fluids as well. Uh it probably would be a good idea to catheterize them to measure urine output, thinking sepsis six here, um, and blood cultures we mentioned already. Now, what am I going to do now about his GCS? I have to make a decision about whether to treat him for a central nervous system infection or not. Um febrile, decreased conscious level, no detected or witnessed neurological impairment. Although we said he might have fitted. Ooh, I think I might, you know. Um, I think I might. Acyclovia, yeah. Acyclovia, very safe drug. Sometimes, of course, it's an AKI, so you have to keep an eye on your function over the next few days. But thinking here and now, we're looking at acyclovir and a lumbar puncture, aren't we? Uh lumbar puncture realistically is going to come first before the MRI scan. And he's a bit of a ropey transfer to MRI at the moment. You'd have to go with anesthetic support in case he lost his airway whilst in the scanner. Um, so I might be lumbar puncturing doing an LP on this chap right there and then resize. There's a good opportunity. GCS 13, he might lie still for it. Okay. Yeah.

SPEAKER_00 21:30

That's not a bad thought, actually. Yeah.

SPEAKER_01 21:34

Yeah. The logistics are always impressive when it comes to lumbar punctures and the acutely sick.

SPEAKER_00 21:41

So, where are you at the moment with what's caused this? So you've mentioned infection, you've got him on kephoroxime, you've mentioned encephalitis, you've started a cyclovia, and you want to do a lumbar puncture on him and sepsis. You've also thought, could this be postictal? And you've also mentioned doxydromes. We don't know which one of those this is at the moment. Correct. What are you going to do apart from the LP?

SPEAKER_01 22:10

Apart from the LP and the resuscitation measures I've mentioned, the LP is realistically going to keep me busy for a couple of hours. Yeah. Finding the kit, getting the position, getting the label, sending them off, all that sort of thing. And I think that's fine. And then I'm going to see what happens next. I'm quite comfortable holding a list of differentials in my head for a few hours and then seeing which one comes to the front of the race as time and results sort of start dripping back. But one thing I could do, I suppose, is ring that very clever poisons helpline and just say, look, I've got a man here. He's febrile, dilated pupils, radapneic, hypoxic, tachycardic, normal muscle tone, I'm assuming, or you would have mentioned that he was hypertonic or or does this fit with any known toxidrome? They're awfully clever, these people. And they might come back and say, you should screen for this or treat for this. This sounds like they could have had um an overdose of this kind of GABA receptor, and maybe you should treat them with baclefen, all that sort of thing. So you might have thought toxidrome, that's a useful resource. Don't do it very often.

SPEAKER_00 23:13

Yeah. So you're talking about calling the National Poisons helpline, the National Poison Agency, or Toxbase as well, which we can also access, can't we? Absolutely. So earlier on, you mentioned that he could have overdosed on a sim how did you say it again?

SPEAKER_01 23:32

Right. Sympath sympathomimetic. Sympatho sympathomimetic.

SPEAKER_00 23:36

Sympathomemetic. How fuss can you say that?

SPEAKER_01 23:40

Sympathometic, sympathometic, sympathomimetic.

SPEAKER_00 23:42

It's really hard, isn't it? Okay.

SPEAKER_01 23:44

It's not as hard as parasympathomemetic, though.

SPEAKER_00 23:46

Oh god, right. I can't even say it. Okay. So you've treated him for everything, and you've mentioned drugs, and absolutely you speak to the National Poisons Agency, which is what I did. Oh, good. And they suggested that yes, this could be a toxidrome. And actually, this could be a potent sympathometic.

SPEAKER_01 24:09

Um, but yes.

SPEAKER_00 24:12

Um, and basically that activates the uh sympathetic nervous system. You've got lots and lots of adrenaline, lots and lots of noradrenaline. Basically, your body goes, heart rate goes up, which you've talked about, your blood pressure goes up, your pupils become very dilated, you become very sweaty and quite agitated, actually. And the things that they suggested that could cause this are cocaine, which you've already mentioned, and amphetamines. Yeah. You did, you did, and spice.

SPEAKER_01 24:40

Okay.

SPEAKER_00 24:41

Yeah. Have you heard of spice? I have. So I don't mean nutmeg, I mean or coriander, I mean a synthetic cannabinoid spice. Yes. Have you seen a lot of people taking this, overdosing this on this?

SPEAKER_01 24:59

To be honest, I haven't. I've seen it more in the news than I have in real life, but um, it can cause profound alterations to mental status, which people could lying can lie there in the street with GCS3 for hours on end before they wake up. Um I don't know if I've I can't remember the last time I ever saw one in in clinical practice though.

SPEAKER_00 25:20

So when I saw this gentleman, he was this was when I was working in Birmingham, inner city Birmingham.

SPEAKER_02 25:27

Yep.

SPEAKER_00 25:28

And we know that inner city Birmingham has a problem with spice. And we know that the biggest cities, Wolverhampton as well, has a particular problem, as well as other um towns and cities throughout England. Spice is a problem, particularly amongst the homeless population. Now, the way that spice works is it is a synthetic cannabinoid, so it activates your cannabinoid one and cannabinoid two receptors completely. So it's a complete agonist of all of the receptors. So you get this extreme sympathetic nervous system stimulation where everything goes wild, and then all of a sudden you get the crash. And that crash can lead to disassociation, decreased UCS, respiratory depression, seizure activity. And there is a thought process that individuals who are homeless, it's particularly prevalent in the prison population as well, because it allows them to dissociate away from actually what is happening to them and get away from the home ketamine.

SPEAKER_01 26:38

Ketamine has a sort of similar yeah, yeah.

SPEAKER_00 26:42

Absolutely. So when I was working in this particular place as well, it was opposite um a very well-known prison. And what I didn't know is that a lot of spice, the latest statistics from 2025 on the government websites are that 50% of prisoners use spice. And that's because spice can be sprayed onto paper and it can be on a letter that's sent in to the prison and it can be ingested. And I remember one of the prison wardens telling me this, and I was like, what? This is crazy. But yeah, it's quite easy to actually get into prisons in that respect. And the fascinating thing about synthetic cannabinoids is it's very difficult to detect on drug tests because the people who make them continuously change the synthesis of the cannabinoid, always evading detection. There is no treatment for synthetic cannabinoid overdose, it's supportive.

SPEAKER_01 27:47

Yeah, yeah, yeah. I suppose the the low respiratory rate threw me there a little bit because I'd expect it, I would expect him to be agitated. But I guess if he's if he's been on it for several hours and it and his nervous system starting to crash, that's very important. Exactly. Um yeah, but treatment is supportive with with things like benzos, uh and and an oxygen, although I wouldn't be giving benzos to someone really with a GCS 13 outside of an HTUI to you setting.

SPEAKER_00 28:14

No, absolutely. And you're absolutely right. So the temperature, you can cool potentially, if that's something that again, I'd probably want to do that in a supportive environment. Um, benzodeazopinge mentioned as well. Again, with the GCS, you'd probably do that when he's more agitated in that sympathetic overdrive rather than the sympathetic crash. Um, ECG can sometimes get prolongation of the QT interval. So you might want to monitor that. Consider maybe magnesium to support the cardiac myosites. Um, check your CK because the CK can still go up. Now, there is also now a huge amount of synthetic opioids. Have you seen anybody overdosing on things synthetic opioids?

SPEAKER_01 28:59

Again, no. I live I live quite a shelter. Life, obviously, unless I've seen them and I've missed it, but um I don't think so.

SPEAKER_00 29:06

So the synthetic opioids, again, made similarly to the synthetic cannabinoids, they're continuously evading detection. They're like they're like a retrovirus. You know, retrovirus are continuously evading detection. That's what these synthetic opioids and um synthetic cannabinoids are, and they're called nit nitazines, I think. Nitazines. Um, I'm right. And um, a lot of people now have polydrug overdose.

SPEAKER_02 29:32

Right.

SPEAKER_00 29:33

So the cannabinoid is mixed in with the opioid. So there is a school of thought that actually, if you have somebody come in who's overdosed and you're not sure what it is, you actually give an aloxone because it might turn off the opioid toxicity.

SPEAKER_02 29:48

Yeah.

SPEAKER_00 29:48

Again, school of thought, something to think about.

SPEAKER_01 29:52

Yeah, yeah. I guess, and I guess if people are coming in with mixed toxidromes, they're going to be harder for us to detect.

SPEAKER_00 29:58

Really hard.

SPEAKER_01 29:59

They're not going to bundle up neatly into a toxidrome we memorized at medical school or we've seen before. A bit of this and a bit of that and a bit of the other. Yeah.

SPEAKER_00 30:08

If you look at the official statistics, the use of spice has gone down. But hidden spice is going up. And what I mean by hidden spice is the spice that may be in prison population, which has been smuggled in, but really scarily, one in six vapes last year that were confiscated on school premises had synthetic cannabinoids in them.

SPEAKER_01 30:34

Oh my gosh. Okay.

SPEAKER_00 30:36

Isn't that frightening?

SPEAKER_01 30:38

Yes, for someone who has a two-year-old daughter who's going to school in a few years. Yeah, that's right.

SPEAKER_00 30:43

Isn't it just? And this takes me back to a couple of patients I've seen within the last couple of years who have had vapes which have been contaminated. And at the time we didn't know what, but actually it probably was synthetic cannabinoids. Scary.

SPEAKER_01 30:58

Well, I tell you what, I have seen a few times is GHB. I think that that's a dissociate has a dissociative effect as well. It does, yeah. And um is used sort of chemsex uh as well, and it causes profound um depression of the consciousness, so much so they can be GCS3, they can be intubated in recass, and the offset is insane to what? It just switches off, they just metabolize it, open their eyes, wake up, yank out their tubes, yank out their cannulus, and walk out the door. And you think, God, that that patient was fully dependent for respiration four seconds ago. It's why all of a sudden they're back, they're back to normal again. But that it's yeah, they're unwakeable, and it's quite shocking how how potent it is.

SPEAKER_00 31:45

Yeah, absolutely. Any thoughts?

SPEAKER_01 31:51

I'm thinking just about I mean, I work in central London. It's not out of the uh limits of possibility that I'm uh these toxidromes will be coming in. Um and I think I think it's something to have a high suspicion for when you see things that don't quite make sense. What made Nego toxidrome when you were telling me this? I think it was the pupils and the temperature, the dilated pupils and the fever. And to me, that speaks of adrenaline, that speaks of your sympathetic nervous system. Um so what would be what would be sort of ramping that up to the max? So I guess that was a little giveaway there for me.

SPEAKER_00 32:25

So this case really made me think about poisoning in general, because I did see a huge amount of, and actually, where I was working was the national, it was where the house of the National Poisons Unit was as well. So I guess I was in a space where I saw lots of these types of cases. So I guess that was a bias in itself. Um, and as you say, sometimes I don't think of toxydromes often enough. I don't think of poisoning enough. And I'm not just talking about poisons from illicit drugs, but I'm also talking of poisons in uh older adults who have a huge anticholinergic burden from the medications that they take. And particularly in the frail elderly population, some of the medications that they are on can give them quite significant anticholinergic side effects that can be incredibly detrimental to them. And it made me think about we should be checking and calculating the anticholinergic burden, which there's a calculator online.

SPEAKER_01 33:27

There is, yeah, yeah, yeah.

SPEAKER_00 33:28

And we can check it does give you a score. Um, for our patients who maybe have a slightly decreased GCS or maybe agitated or complaining of symptoms that we really can't put our finger on, think drugs, think medication.

SPEAKER_01 33:44

Yeah. So yeah. And the high the anticholinergic toxicity sort of looks a bit like this. Yes, a bit hyperthermic. Um, you go into urinary retention. Uh you can get those dilated pupils and get a delirium as well. What's the main culprit drugs that you see in clinical practice?

SPEAKER_00 34:02

Anticolinergics. So some of the antidepressants can do it.

SPEAKER_01 34:06

Amitrypsiline.

SPEAKER_00 34:07

Amitrypsiline, which seems to be quite commonly prescribed 10 milligrams noctate.

SPEAKER_01 34:13

Yeah. Hopefully, not so much anymore. But yes. Someone, you know, if someone says, Oh, I've started them on a bit of amitryptilin for their pain. And that's a bit brave. In an older adult, that's a little bit brave for me.

SPEAKER_00 34:29

Yeah. What about you? What sort of anti-cholinergic drugs are you seeing?

SPEAKER_01 34:33

What's the one they give for bladder overactivity?

SPEAKER_00 34:36

Oxy oxybutanin or yeah, yeah.

SPEAKER_01 34:38

Solophenosin, those. They're they're not uncommon in elder adults as well, and they they can do it as well. Um, I think also Tramadol can have a quite a um a cholinergic burden as well. Um, and I do see that sometimes. And Tramadol is such an ineffective painkiller. We really shouldn't be giving it to anybody.

SPEAKER_00 34:58

No, exactly. I'm just um I agree. And I think years and years ago, Tramadol was like the big um drug, wasn't it? But it's not something again that we tend to see a lot of anymore.

SPEAKER_01 35:11

I remember when I was a foundation doctor as part of our normal post-operative um packet of drugs, we'd send patients home after they'd had surgery, paracetol and the tramadol. Yeah. Um, whereas now you give tramadol and everyone sort of reacts as if you're holding garlic up to a vampire.

SPEAKER_00 35:26

Throw it away, throw it away. Yeah. But also Certralein as well can have quite an anticholinergic burden, which is often used in the elderly as an antidepressant because it has less cardiovascular side effects. So again, it's that balancing act, isn't it, of of risks versus benefits of the medication.

SPEAKER_01 35:46

And there's a synergism, you know, they work together. So three of them. Yeah.

SPEAKER_00 35:50

Yeah, absolutely. So I hope that was an interesting case for you, Ben, and it got you thinking.

SPEAKER_01 35:58

I love cases like that. And I love I love working in cases of that. I was going to say it when um when we we were in resat when I was looking at the patient. I'm having such a nice time. I it's such a good day at work. I I really I really enjoy that side of medicine, that side of acute medicine, um, and sort of puzzling stuff out and resuscitating, you know, and treating patients who need you and but also got your thinking cap on at the same time. That feeds my soul a little bit while going to work.

SPEAKER_00 36:24

It's like that is what we do as acute physicians, isn't it? Yeah. That's what I love doing. Yeah. So I'm gonna end on a quote from Paracelsus. Have you heard of Paracelsus? No. I can't believe it. So Paracelsus was a physician um donkey a long, long, long time ago, like the 1600s, 1700s, and he said, everything is poisonous, it's the dose that determines it. And also, what I really liked about this, um, this gentleman was that he was very um new in his way of thinking, and he was very sort of anti-the Greek way of medicine. And he was very much one of his sayings, I mean, you don't know whether this was actually said or not, because it was four or five hundred years ago, but he was the first physician who said looking at the patient is where you get the clues. So I really like that. It absolutely. Um, so well done, Paracelsus. Uh and um, Ben, thank you so much. We've covered so many things there. We've covered toxidrones, polydrug poisoning. And I think the key thing there is to our listeners is to think anticholinergic burden, think spice, think synthetic drugs because they sometimes evade detection.

SPEAKER_01 37:49

And if in doubt, ring an expert. Ring an expert. Exactly. Sounds like we're very helpful in your case.

SPEAKER_00 37:55

Yes. Thank you to everybody for listening. Please rate a review and subscribe to the podcast. Thanks for listening. Goodbye.

SPEAKER_02 38:04

Bye.