A 40-year-old man with a history of substance use disorder was found unresponsive and taken to the ED by EMS. No information was known regarding his downtime.www.shutterstock.com.EMS administered two doses of intranasal naloxone (2 mg), and he was placed on a non-rebreather oxygen mask. The patient was unable to hear upon awakening, and it was determined he had complete bilateral hearing loss. He was able to communicate by writing. His wife confirmed he had used fentanyl and cocaine. He had a heart rate of 115 bpm, blood pressure of 123/59 mm Hg, respirations of 18 bpm, temperature of 36.2°C, and an oxygen saturation of 70% on room air. He was administered an additional dose of IV naloxone (2 mg). His oxygen continued to desaturate, and he was placed on BiPAP. ED laboratory studies revealed an elevated potassium at 7.4 mmol/L, an elevated BUN (34 mg/dL), and elevated creatinine (2.82 mg/dL), indicating acute renal failure. A venous blood gas showed a pH of 6.96, a lactate of 4.7 mmol/L, a CO2 of 85.1 mm Hg, and an HCO3 of 19.9 mmol/L. His creatinine kinase was elevated at 19,964 U/L. His urine drug screen was positive for fentanyl, cocaine, and cannabinoids. An electrocardiogram showed sinus tachycardia and mildly peaked T-waves. The patient was given 1 g of IV calcium gluconate three times over five hours. A chest x-ray was positive for pneumonia (likely aspiration), and the patient was started on IV ampicillin-sulbactam. Nephrology called in the dialysis team for emergent dialysis. The patient developed hypotension and a 16 mg IV infusion of norepinephrine was initiated. He remained hypotensive, and a vasopressin infusion of 0.03 units per hour was added. He was also given three ampules of sodium bicarbonate in the ED and was started on a bicarbonate drip. He was transferred to the medical intensive care unit. The patient's creatinine levels, hyperkalemia, and hearing improved after three hours of emergent dialysis. He was weaned off BiPAP while in the hospital, continued to improve, and was discharged on day seven. AN UNUSUAL SEQUELA Approximately 115,000 people had a fatal overdose worldwide in 2017, and the number of nonfatal overdoses was several times higher. (World Health Organization. 2023; https://tinyurl.com/ytyhrrww). Nonfatal overdoses and opioid-related deaths have increased in recent years. (CDC. 2023; https://tinyurl.com/489ahp82). Typical symptoms of an overdose include pinpoint pupils, respiratory depression, and decreased consciousness. (StatPearls [Internet]. Treasure Island [FL]: StatPearls Publishing; Jan 2023; https://tinyurl.com/ywk7t27t). Respiratory depression associated with overdose can result in hypoxia, rhabdomyolysis, and death. (Drug Alcohol Depend. 2021;226:108838; https://tinyurl.com/msbfse68; Drug Alcohol Depend. 2021;225:108830; Drug Alcohol Depend. 2018;190:112; https://tinyurl.com/5u2tsr35). Rhabdomyolysis is the degradation of muscle cells and their contents into the bloodstream, which can have longstanding effects, including acute renal damage and subsequent renal failure. (Epidemiol Health. 2017;39:e2017050; https://tinyurl.com/2s46mwn8). Rhabdomyolysis is generally characterized as a serum increase of creatine kinase of at least 10 times the upper limit of normal. Rhabdomyolysis can also cause electrolyte abnormalities, including hyperkalemia, hyperphosphatemia, hypocalcemia, and hypomagnesemia, leading to cardiac arrest and acute kidney injury. (Neuromuscul Disord. 2014;24[8]:651; Trauma Surg Acute Care Open. 2022;7[1]:e000836; https://tinyurl.com/y5m6s9xf). A less common sequela to an overdose is sensorineural hearing loss (SNHL). The pathophysiology is unclear, and there is no literature on SNHL resolution with dialysis. (J Med Toxicol. 2020;16[4]:416; https://tinyurl.com/msupzyyp). SNHL is an unusual side effect of opioid overdose, although cases have increased recently, especially in young patients. (Addict Health. 2018;10[1]:64; https://tinyurl.com/4azzm34f). SNHL has also been reported in patients using cocaine or a combination of cocaine and opioids. (J Am Acad Audiol. 2008;19[6]:461; Int J Environ Res Public Health. 2021;18[22]:11945; https://tinyurl.com/3j6nnmc2; Cureus. 2021;13[12]:e20686; https://tinyurl.com/2xayzv6s). Some cases are irreversible, require a cochlear implant, and can be associated with tinnitus and vertigo. (Addict Health. 2018;10[1]:64; https://tinyurl.com/4azzm34f). Hearing loss that resolves usually follows a steroid taper. Current clinical trials are comparing outcomes between dexamethasone and prednisone for sudden SNHL. (J Am Acad Audiol. 2011;22[4]:208; ClinicalTrials.gov. https://tinyurl.com/2s3dfzd2). KIDNEY DISEASE AND SNHL The patient in this case experienced transient acute hearing loss following an opioid overdose with secondary rhabdomyolysis that resolved after one round of dialysis. A great deal of literature exists on overdose and hearing loss, along with case reports of overdoses detailing a similar disease process. (J Am Acad Audiol. 2008;19[6]:461; Int J J Am Acad Audiol. 2011;22[4]:208; Case Rep Otolaryngol. 2014;2014:962759; https://tinyurl.com/yeywwwm4; Emerg Med. 2012;44[11]:4; https://tinyurl.com/bdevtwkw). A process other than ototoxicity may be causing hearing loss if multiple drugs taken in excess can cause SNHL. A correlation between kidney disease and sensorineural hearing loss has been shown. (Sci Rep. 2021;11[1]:20194; https://tinyurl.com/us49pypr; J Laryngol Otol. 2019;133[7]:592.) SNHL is more prevalent in patients with CKD and has shown a suggestive link without a known etiology. (Am J Med. 2016;129[4]:416; https://tinyurl.com/mpbnsjjn; Ren Fail. 2018;40[1]:170; https://tinyurl.com/37t8k2kd). One commonly cited possibility in the association of hearing loss and kidney injury is electrolyte disturbances. (Am J Med. 2016;129[4]:416; https://tinyurl.com/mpbnsjjn; Ren Fail. 2018;40[1]:170; https://tinyurl.com/37t8k2kd; J Evol Med Dent Sci. 2014; 3[4]:1034; https://tinyurl.com/yuuh25fx). Further research should be done to determine if causation exists between electrolyte homeostasis and hearing loss. This patient also suffered rhabdomyolysis. Many cases have reported patients experiencing rhabdomyolysis and hearing loss due to an overdose on various agents, but this is the first case where acute SNHL due to an opioid overdose resolved after hemodialysis. (Ear Nose Throat J. 2021;1455613211069353; https://tinyurl.com/464eb35u; Subst Abuse Treat Prev Policy. 2019;14[1]:48; https://tinyurl.com/ys4jwj8t; J Cardiovasc Dis Res. 2013;4[1]:55; https://tinyurl.com/2shr46bu). Patients experiencing an overdose may present with bilateral SNHL. (Kans J Med. 2021;14:253; https://tinyurl.com/3b5twv7r). Dialysis may correct metabolic derangements and improve hearing loss for patients with an acute overdose and rhabdomyolysis causing acute renal failure. Reprinted with permission. Emergency Medicine News. 2024;46(4A); https://tinyurl.com/w3aee3tb.
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