266 Emergency Medicine
246.The answer is e.(Rosen, pp 2180-2185.)Hydrocodone is an opioid
used for pain relief. Opioid withdrawaloccurs in tolerant individuals
when opioid exposure is discontinued or an antagonist is administered. The
effects of withdrawal are secondary to increased sympathetic discharge,
which is responsible for the clinical signs and symptoms. Although these
can be significant, they are typically not life-threatening. Withdrawal is asso-
ciated with CNS excitation, tachypnea, and mydriasis. Pulse and BP may be
elevated. The patient may present with nausea, vomiting, diarrhea, abdomi-
nal cramps, myalgias, and insomnia. Examination often reveals piloerection,
yawning, lacrimation, rhinorrhea, and diaphoresis. Neurologic manifesta-
tions include restlessness, agitation, and anxiety, but cognition and mental
status are unaffected. Dysphoria and drug craving are usually prominent.
(a and b)Amitriptyline is a TCA that has anticholinergic properties.
Overdose of TCAs results in toxicity by a number of different mechanisms.
The anticholinergic properties of TCAs results in the toxidrome “blind as a
bat (mydriasis), red as a beet (flushed skin), hot as a hare (hyperthermia sec-
ondary to lack of sweating), dry as a bone (dry mucous membranes).” The
cardinal signs of TCA overdose include ventricular dysrhythmias, hypoten-
sion, and decreased mental status. (c)Early alcohol withdrawal may occur
6 hours after cessation or decrease of alcohol consumption. It is characterized
by autonomic hyperactivity: nausea, anorexia, coarse tremor, tachycardia,
hyperreflexia, hypertension, fever, decreased seizure threshold, hallucina-
tions, and delirium. (d)Serotonin syndrome occurs when a serotonin
reuptakeinhibitor is combined with another drug that potentiates serotonin.
The opioid meperidine (Demerol), but not hydrocodone, is known to poten-
tiate serotonin. It presents with abdominal pain, diarrhea, diaphoresis, hyper-
pyrexia, tachycardia, hypertension, myoclonus, irritability, agitation, seizures,
and delirium.