What is the most appropriate next step in managing a patient with suspected methamphetamine intoxication, presenting with agitation, tachycardia, diaphoresis, and altered mental status, after administration of benzodiazepines?

Determine Core Temperature Immediately

The most appropriate next step is to determine the patient's core temperature, as methamphetamine intoxication commonly causes life-threatening hyperthermia that requires urgent recognition and aggressive management to prevent mortality from multi-organ failure. 1

Why Core Temperature Assessment is Critical

• Hyperthermia is a major cause of death in sympathomimetic toxicity, presenting with the exact constellation of symptoms seen in this patient: agitation, tachycardia, diaphoresis, and altered mental status 1
• The patient demonstrates classic signs of a hyperthermic toxidrome: flushed skin, diaphoresis, tachycardia, and severe agitation requiring high-dose benzodiazepines 1
• Management of hyperthermia often involves terminating extreme muscle activity through benzodiazepines (already administered) or, in severe cases, paralysis with nondepolarizing agents and intubation 1
• Core temperature measurement is essential because clinical presentation alone can be misleading—patients may appear less critically ill than their actual physiologic state 2

Why Other Options Are Less Urgent

Haloperidol Administration

• Antipsychotics are controversial in sympathomimetic toxicity due to potential for lowering seizure threshold, prolonging QT interval, and decreasing heat dissipation 3
• While some evidence suggests antipsychotics may be safe, there is no clear benefit over benzodiazepines, which have already been administered 3
• The patient has already received appropriate first-line treatment (high-dose benzodiazepines) 1, 4

Electrocardiogram

• While ECG is important for detecting arrhythmias and QT prolongation in stimulant toxicity, it is not the most immediately life-threatening concern 1
• ECG should be obtained but can be performed after assessing for hyperthermia 1

Urine Drug Screen

• Urine drug screens do not change acute management and should not delay critical interventions 1
• The history already strongly suggests methamphetamine intoxication
• Results take time and will not alter immediate treatment decisions

Critical Management Algorithm After Temperature Assessment

If core temperature is elevated (>40°C/104°F):

• Initiate aggressive cooling measures immediately 1
• Consider paralysis with nondepolarizing agents (vecuronium or rocuronium) and intubation for severe cases 1
• Avoid succinylcholine due to risk of hyperkalemia and rhabdomyolysis 1
• Antipyretics are typically ineffective because fever is secondary to muscular hyperactivity, not hypothalamic dysregulation 1

Regardless of temperature:

• Continue benzodiazepines as needed for ongoing agitation 1, 4
• Monitor for rhabdomyolysis (check creatine kinase) 2
• Provide supportive care with IV fluids for potential hypotension 1

Common Pitfalls to Avoid

• Do not delay temperature assessment—hyperthermia can rapidly progress to multi-organ failure and death 1
• Avoid beta-blockers in acute methamphetamine intoxication due to risk of unopposed alpha-stimulation and worsening hypertension 1
• Do not rely on clinical appearance alone—patients may appear more stable than their core temperature indicates 2
• Use low-reading thermometers capable of detecting severe hypothermia or hyperthermia accurately 2