PEERS RESPOND

ANDREA WARD

Initial Post: Andrea Ward

Scenerio :A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. The patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.

The role genetics plays in disease.

            Substance abuse has a complex etiology which is influenced by many things. Genetic factors can play a large role in an individual's susceptibility to substance abuse in several ways. Certain genetic variations may increase the risk of developing substance use disorders. These genetic factors can influence the brain's reward pathways, making some individuals more susceptible to the reinforcing effects of drugs. For example, “Genes that code for cytochrome enzymes in the liver (CYP variants) can influence how quickly an individual metabolizes a drug, which influences how they respond to medications and other substances” (Mosel,2023). Variations in drug metabolism enzymes can influence the intensity and duration of the drug's effects. Therefore, a person with a genetic predisposition for slower metabolism of a particular substance may experience more prolonged and intense effects, potentially increasing the risk of substance abuse.

Why the patient is presenting with the specific symptoms described.

            The patient was found to be unresponsive with an unknown amount of downtime lying on the floor. The patient is unresponsive due to the toxic levels of the drugs in the body which surpasses the body's ability to metabolize and eliminate it. The substance which was taken by the patient caused respiratory depression and lack of oxygen to the brain as well as other organs. After the Naloxone was given the patient complained of burning over his left hip and forearm. The ED evaluation revealed that the patient had a large among of necrotic tissue over his hip and  The burning pain and necrotic tissue are a result of vasoconstriction and tissue hypoxia caused by increased intracellular calcium. The EKG shows prolonged PR interval and peaked T- waves. The peaked T- waves are an indicator of high potassium. Which is correlated with the serum potassium of 6.9 meq/ml. 

The physiologic response to the stimulus presented in the scenario and why you think this response occurred.

Opioids suppress the respiratory system. Leading to slow and shallow breathing, or respiratory arrest. The patient may become hypoxic due to his inability to ventilate himself properly. Which leads to his decreased level of consciousness. Due to his inability to ventilate and oxygenate himself properly the body naturally delivers the oxygen first to the main organs. When muscle and tissues do not get enough oxygen the membrane structure deteriorates and causes cell death. His body is going through rhabdomyolysis. According to the Cleveland Clinic (n.d), during rhabdomyolysis the muscles breakdown and deteriorate into your blood. This includes large amounts of Potassium, Phosphate, Myoglobin, Creatinine Kinase, and urate. Since the Kidneys are responsible for removal of these components from your blood, thru urine. The inability of the kidneys to function properly causes kidney damage, electrolyte abnormalities, and metabolic acidosis. Necrosis happens when there is a “rapid loss of plasma membrane structure, organelle swelling mitochondrial dysfunction and lack of typical features of apoptosis” (McCance, K. L. & Huether, S. E. (2019).  So, the lack of oxygenation to the cells caused the cells to breakdown and auto digest. Due to the membrane integrity being lost, the necrotic cell contents leaked out into the tissue.

The inability to excrete Potassium led to the 6.9 meq/ml of potassium in the blood and the peaked T-waves. T waves represent repolarization of the ventricles. During repolarization there is movement of the potassium ions into the cell. Therefore, the peaked T-waves are due to delayed repolarization from excess amount entering the cell.

The cells that are involved in this process.

In an opioid overdose, the primary cells involved in the physiological response are neurons in the brain and spinal cord. Opioids bind to specific opioid receptors which inhibit the release of certain neurotransmitters. According to Rameriez et. al, Opioid receptors are plentiful in the brainstem, specifically in the medulla oblongata. The medulla oblongata is critical for controlling autonomic functions such as respiration and cardiovascular activity. By administering the naloxone, it reversed the effects of the opioid by binding to those receptors. Waking the patient up.

Skeletal muscle cells are the main cells involved in rhabdomyolysis. These cells make up the skeletal muscles, which are under voluntary control and are responsible for body movement. When these cells become damaged or injured, the contents of the muscle cells, including myoglobin’s, get released into the bloodstream. Myoglobin, which is found in muscle cells, is responsible for storing and transporting oxygen. When the muscle cells are damaged, myoglobin is released into the bloodstream. High levels can lead to kidney damage, as the kidneys can struggle to filter and excrete a large amount of this protein.

                                                                                               

How another characteristic (e.g., gender, genetics) would change your response.

If the patient were female, the scenario might differ. This is because men generally exhibit a greater muscle mass. Consequently, rhabdomyolysis could potentially result in more severe cases in men compared to women, given their elevated muscle mass. “The incidence of rhabdomyolysis is higher in males than in females, especially in the subgroups of patients with trauma and inherited enzyme deficiencies” (Morales De Guzman, 2021). Understanding the individual's medical history, including any gender-specific risk factors, can guide the diagnostic and management approach of rhabdomyolysis.

 

 

BROOK HURST

Main Posting Response:

The Role Genetics Play

Scientists have discovered through data taken from over 1,000,00 people that genes are commonly inherited across addiction disorders, regardless of the substance being used. Substance use disorders are inheritable by complex genes and multiple environmental factors. (NIDA 2023) Through a lot of research, it has been found that genomic patterns can predict whether a person will have a genetic predisposition to substance use disorders. However, I do not believe that genetics lead to the necrosis that the patient had suffered or hyperkalemia.

Symptom Presentation, Physiologic Response, and Cells

Narcan is an opioid antagonist, meaning that it attaches to the opioid receptors in the brain and blocks the effects of the opioids being used. (NIDA 2022) This could explain why the patient began to complain of the pain that was associated with the necrosis on the left hip and forearm. When it comes to the necrosis in the hip, we can assume that the tissue had became infected and died via autolysis. After research into causes of these symptoms, we can also assume that the patient is in a state of rhabdomyolysis. Rhabdomyolosis can be drug induced and can lead to the interference of ATP production, leading to the death of the tissue. (Cabral et, al. 2020) One of the symptoms of rhabdomyolysis includes hyperkalemia. With the destruction, ATP depletion causes intracellular calcium to increase. The plasma membrane of the cells is supposed to exchange calcium for potassium. The increased number of calcium, leads to the inability to exchange the appropriate amount of potassium, leading to hyperkalemia. (Cabral et, al. 2020) According to many studies, hyperkalemia can lead to noticeable EKG changings. With the change in the potassium level, there is change in the electrical gradient across the membranes of the cell. This can lead to increased usage of the cardiac muscles and rapid repolarization of the ventricles, leading to peaked T-Waves on the EKG. (Parham et. all, 2006)

Other Characteristics

It would be interesting to know how long the patient has been unconscious prior to EMS arriving and administering the narcan. Something else that may change the outcome of my thought process would be to know how long the necrotic tissue had been there prior to the patient overdosing. Could it had been caused by a used needle, which lead to infection? How long had the patient been in active use prior to this event? I am unsure that the sex of the individual would change my response to the scenario.