Case files of the University of Massachusetts Fellowship in Medical Toxicology: Lethal dose of opioids contained in an elastomeric capsule labeled as vancomycin

Abstract

A 67-year-old man presented to the emergency department (ED) with an alteration in mental status. His past medical history included hypertension, hyperlipidemia, vitamin B 12 deficiency, and recurrent cellulitis. In addition to aspirin, atorvastatin, cyanocobalamin, and multivitamins, he received vancomycin 1 g IV every 12 hours via a peripherally inserted central catheter for MRSA cellulitis. Approximately 30 minutes after his wife began his most recent infusion of vancomycin, the patient began slurring his speech. When he became difficult to arouse, his wife activated Emergency Medical Services. The ambulance crew found the patient to be somnolent, but arousable, and breathing adequately. During transport to the ED, however, the patient became unresponsive and had depression in respiratory effort to the point that he required assisted ventilation with supplemental oxygen.On arrival to the ED the patient's vital signs were: pulse 110 per minute, blood pressure 173/83 mmHg, respiratory rate 4 per minute, oxygen saturation 57% while being assisted with 100% oxygen via bag valve mask, and temperature 36.1Њ C. On physical examination, there were no signs of physical trauma and pupils were 1-2 mm bilaterally. The patient had agonal respirations with rhonchi heard throughout the lung fields. Other than tachycardia, the cardiovascular and abdominal exams were without gross abnormalities. His skin was ashen, cool, and dry, with delayed capillary refill. The neurological examination showed no spontaneous movements and no response to painful stimuli. Because 2.2 mg IV naloxone produced no improvement in respiratory depression, the patient was endotracheally intubated. Although the patient's wife denied access to or the use of narcotics, the patient's qualitative comprehensive urine toxicology screen (which could identify 1043 drugs and other chemicals) detected morphine, codeine, and naloxone.