ABSTRACT
We present two rare cases highlighting the rare toxicological manifestation of dextromethorphan (DXM). The DXM toxicity profile is predominantly hallucinations, agitation, irritability with seizures, and coma in severe overdose. The cases that follow are unique in the sense that both patients had features of opioid toxidrome, rarely manifested in DXM abuse. A young male and female in their mid-20s and early 30s, respectively, were brought to the emergency room for their excessive somnolence; both had reduced respiratory rate, bilaterally small pupils (sluggish reactive to light), and the rest of their examination findings were unremarkable. Primary stabilization in the form of noninvasive ventilation (NIV) trial and subsequent rapid sequence intubation (RSI) for persistent respiratory depression. Followed by the exhaustive exclusion of differentials, opioid-like toxidrome was treated with naloxone, and both patients made a good recovery and were discharged home in good health. The emergency physician should be prepared for the rare toxicological manifestations of commonly available over-the-counter medications among the youth. These case reports highlight the role of naloxone in DXM toxicity reversal.
ABSTRACT
Background: The application of a risk stratification pathway is necessary for the emergency department (ED) to assess the severity of the disease and the need for escalation of therapy. We aimed to implement the National Early Warning Score 2 (NEWS2) pathway at triage to differentiate patients who are stable or critically ill with no invasive investigations at the time of admission during the coronavirus disease of 2019 (COVID-19) era in comparison to other clinical risk scores. Methods: One hundred and four patients were collected from April 1, 2021, to June 1, 2021, during the second wave of the COVID-19 pandemic at an academic medical center in India. The NEWS2 scoring system and the quick sepsis-related organ failure assessment (qSOFA) score were introduced as part of the initial assessment in the triage area of the ED. Data were assessed using the area under the receiving operating characteristic (AUROC) curve for NEWS2 and qSOFA scores, respectively. Results: In the study, NEWS2 classification indicated that 25% of patients required continuous monitoring, of which 12.7% subsequently deteriorated within 24 h of admission and 7% died. Both, NEWS2 (threshold 0; 1, AUROC 0.883; 95%; confidence interval [CI] 0.8-0.966) and qSOFA (threshold 0; 1, AUROC 0.851; 95% CI 0.766-29 0.936) effectively identified COVID-19 patients in the ED at risk for clinical deterioration. There was no significant difference in the diagnostic performance of qSOFA and NEWS2 (DeLong's test P = 0.312). Conclusion: Both NEWS2 and qSOFA effectively-identified COVID-19 patients in the ED at risk for clinical deterioration with no significant statistical difference. However, a triage level risk stratification score can be developed with the inclusion of blood parameters on admission to further validate the practice.