A 40-year-old drug addict was found in a drowsy state on road. He was severely malnourished, cachectic and dehydrated. His blood pressure was 70 mm of Hg.

Initial Assessment and Stabilization

The first priority is to assess and stabilize the patient’s vital functions. This involves a rapid primary survey following the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).

• Airway: Ensure a patent airway. Consider oropharyngeal or nasopharyngeal airway if necessary.
• Breathing: Assess respiratory rate and effort. Provide supplemental oxygen via nasal cannula or mask.
• Circulation: Blood pressure of 70 mmHg is critically low. Immediate intervention is required.
• Disability: Assess neurological status using the Glasgow Coma Scale (GCS).
• Exposure: Fully expose the patient to assess for any injuries or signs of intravenous drug use (track marks).

Management of Hypotension and Dehydration

The patient’s severe hypotension requires immediate fluid resuscitation.

• Intravenous Fluids: Initiate rapid infusion of crystalloid solutions (e.g., Normal Saline or Ringer’s Lactate). Start with a bolus of 500ml-1L, reassessing blood pressure and urine output after each bolus.
• Vasopressors: If hypotension persists despite adequate fluid resuscitation, consider vasopressors (e.g., norepinephrine) under close hemodynamic monitoring.
• Monitoring: Continuous cardiac monitoring, pulse oximetry, and frequent blood pressure checks are essential.

Addressing Malnutrition and Cachexia

Severe malnutrition and cachexia require a phased approach to nutritional support.

• Initial Phase: Start with intravenous nutrition (Total Parenteral Nutrition - TPN) to provide essential nutrients while the gastrointestinal tract recovers.
• Enteral Nutrition: As the patient stabilizes, transition to enteral nutrition (tube feeding) if possible, as it is physiologically more beneficial.
• Electrolyte Correction: Correct any electrolyte imbalances (e.g., hypokalemia, hypomagnesemia) which are common in malnourished individuals and can exacerbate cardiac arrhythmias.

Identifying the Underlying Cause

Determining the specific drug involved and the nature of the presentation (overdose, withdrawal, or complication) is crucial.

• Toxicology Screen: Obtain a comprehensive toxicology screen to identify the substances present in the patient’s system.
• Withdrawal Syndrome Assessment: Assess for signs of withdrawal from common drugs of abuse (opioids, alcohol, benzodiazepines). Specific withdrawal scales (e.g., CIWA-Ar for alcohol withdrawal) can be used.
• Differential Diagnosis: Consider other potential causes of hypotension and altered mental status, such as sepsis, internal bleeding, or cardiac arrhythmias.

Specific Drug-Related Considerations

Drug Class	Potential Complications	Specific Management
Opioids	Respiratory depression, overdose, withdrawal	Naloxone administration (for overdose), supportive care for withdrawal
Stimulants (Cocaine, Amphetamines)	Hypertension, arrhythmias, seizures, hyperthermia	Benzodiazepines for seizures, cooling measures for hyperthermia
Alcohol	Withdrawal seizures, delirium tremens, liver disease	Benzodiazepines for withdrawal, thiamine administration

Further Investigations

Additional investigations may be necessary to identify underlying complications:

• Complete Blood Count (CBC): To assess for anemia or infection.
• Electrolyte Panel: To identify and correct electrolyte imbalances.
• Renal Function Tests (RFT): To assess kidney function.
• Liver Function Tests (LFT): To assess liver function.
• Chest X-ray: To rule out pneumonia or other lung pathology.
• Electrocardiogram (ECG): To assess for cardiac arrhythmias.