1. Did he get injury? Dr. Law chi yin PYNEH

2. One Saturday afternoon young man age 32 Sent to AED by ambulance Fixed by spinal board and neck collar Claimed back pain after jumping from the second floor of a building, He was chased by 30 persons

3. One Saturday afternoon He called ambulance in a MTR station after quarreling with his girl friend Accompanied with a girl who could provide only limited information

4. In the triage station He was alert Bp 145/100 mmHg Pulse rate 104 bpm Temp 36 o C RR 16 SpO 2 100% room air

5. Seen by MO 10 minutes later GCS E 4 V 4-5 M 6 Agitated with confused words No alcoholic smell Denied taking drugs

6. Seen by MO 10 minutes later With history of trauma and altered mental status Transported to resuscitation room –Set drip –Trauma series X-ray with lumbar spine –FAST scan

7. In Resuscitation room Agitated Struggling around No external wounds PERL 4 mm ABC was good,

8. In Resuscitation room Chest, abdomen, pelvis and limbs were normal No spinal tenderness No focal neurological signs

9. In Resuscitation room Sugar 6.8 ECG sinus VR 110 bpm, QRS 90ms X-ray, trauma series, L-spine all normal US abdomen showed no fluid

10. In Resuscitation room He was agitated and uncooperative during examination and X-ray taking 5 mg valium was given intravenously in order to calm him down

11. In Resuscitation room Did he get injury? What caused his agitation?

12. In Resuscitation room Foley was inserted Urine was tested for toxicology It showed positive for amphetamine With this evidence He then admitted that he had taken “ICE” before quarreling with his girl friend

13. He was admitted medical ward CT brain was normal Blood tests were normal Mental status was improved after admission Psychiatrist was consulted Put on haldol and ativan Home after 3 days admission

14. History reviewed Known ex-IVDA Amphetamines and heroin abuser Took 3 tablets of “ICE” before quarrelling with his girl friend He really had back injury 2 days before he attended AED

15. Learning points CNS stimulants causes hyper-alert, agitation, confusion, seizure and coma It depends on the severity of overdose Light overdose may be difficult to recognize and diagnose

16. Learning points Sympathomimetic toxidrome may not be evidenced, especially for chronic abuser in light overdose Substance abuser may deny taking drugs

17. Learning points Common amphetamines –Methamphetamine (Ice) –MDMA (Ecstasy)

18. Learning points Methamphetamine –name: crystal, ice, tina or meth –Route: insufflation (inhale powder) inhalation (smoke), IV or PO MDMA –Ecstasy in tablet form

19. Learning points Common features for amphetamine overdose –CNS stimulation: agitation, insomnia, confusion, fit, psychosis. –CVS: high BP, fast pulse, tachypnoea, –Hyperthermia, sweating, dehydration

20. Learning points methamphetamine overdose Tweaking –psychomotor agitation –psychiatric symptoms mimic schizophrenia Strange history may be caused by delusion and hallucination

21. Leaning points DDx for abnormal agitation –body packer or stuffers –CNS stimulants overdose Cocaine Amphetamine (Ice or Ecstasy) Ketamine –Drugs withdrawal Alcohol Benzodiazepine

22. Leaning points –Non toxic causes Hypoglycemia Hypoxia Shock Thyrotoxicosis Head injury, SAH or meningitis Psychiatric disorder