Background: Synthetic Cannabinoid (SC) intoxication has become difficult to diagnose and manage in the United States in part due to varying clinical effects within this heterogeneous group of compounds. Case Report: A 38 year-old male was admitted with altered mental status and bradycardia. He demonstrated progressive encephalopathy, seizure activity, second degree atrioventricular (AV) block, type I, respiratory failure, hypotension, hypothermia, and hypoglycemia. A computed tomography (CT) abdomen and pelvis revealed multiple packages in the patient’s stomach and rectum. Multiple attempts at gastrointestinal decontamination were unsuccessful. On hospital day eight the patient developed hypertensive emergency and was taken to the operating room for exploratory laparotomy. Twenty-two poorly wrapped packages were removed from the bowel. Post-operatively the patient demonstrated both generalized and focal seizure activity. His mental status slowly returned to baseline over the period of about one week and he was ultimately discharged without neurological sequelae after one month. Analysis of patient serum, urine, and plant matter from packages identified cannabis and 2.N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-carboxamide (ADB-FUBINACA). Why should an emergency physician be aware of this?: The case presented demonstrates the suspected toxidrome associated with severe ADB-FUBINACA intoxication including mental status depression, bradycardia, autonomic instability, seizure, hypoglycemia, and hypothermia. Although the patient had simultaneous exposure to cannabis, his constellation of symptoms is not consistent with cannabis intoxication. A previous animal model supports the potential of this specific SC to cause the reported toxidrome.

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