Publication Date: August 2018 (Volume 20, Number 8)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 8/1/2021
Specialty CME Credits:: Included as part of the 4 credits, this CME activity is eligible for 1 Behavioral Health CME and 3 Pharmacology CME credits, subject to your state and institutional approval.
A 25-year-old woman is found at a bus stop by bystanders after a “syncopal” episode. The patient was seen stumbling as she attempted to board a bus, and she exhibited an apparent lack of coordination. Upon arrival to the ED, the patient states that she feels fine, and “everything is OK. I only smoked a little pot.” On evaluation, the patient is seated comfortably on the stretcher and is pleasant during the history and physical examination. She reports a past medical history of anxiety, but nods off during questioning. Her vital signs are: heart rate of 107 beats/min; respiratory rate, 16 breaths/min; blood pressure, 135/77 mm Hg while seated; temperature, 37.2°C; and oxygen saturation, 98% on room air. Upon examination, you note the patient has conjunctival injection, dry oral mucosa, and tachycardia, but an otherwise unremarkable examination, including neurologic assessment. At the end of your encounter, the patient says “thanks,” and requests to leave the ED for work. You wonder whether she should have a syncope workup and be kept in observation. Because you suspect marijuana intoxication, you wonder whether she should be advised to not go to work.
As you proceed to log into the EMR, EMS arrives with a 17-year-old previously healthy boy with tachycardia and violent behavior. The patient’s mother called 911 because she found him behaving strangely when she arrived home from work. The patient appears very agitated and is unable to remain seated on the stretcher during the clinical encounter. The patient reports chest pain and palpitations. His vital signs are: heart rate, 146 beats/min; blood pressure, 169/99 mm Hg; respiratory rate, 21 breaths/min; temperature, 38°C; oxygen saturation, 100% on room air; and fingerstick glucose, 65 mg/dL. Could this be an overdose or toxic ingestion? What further diagnostic tests and/or interventions should be initiated, if any?