Opioid contamination of recreational substances has become a significant contributor to overdose-related morbidity and mortality in the United States. The co-use of opioids and stimulants produces a mixed toxidrome combining opioid-induced central nervous system depression and immobilization with stimulant-associated vasospastic and prothrombotic effects. We report a survivor of an overdose event in which multiple individuals unknowingly used fentanyl-contaminated cocaine at a social gathering. Two individuals were found deceased at the scene, while a 53-year-old man was found unresponsive but survived, likely due to positional airway protection. On presentation, he was hypertensive and confused, with significant right-sided soft tissue swelling. Urine analysis was positive for cocaine and fentanyl. Laboratory evaluation revealed markedly elevated creatine kinase levels, and imaging demonstrated an acute small vessel infarct in the left corona radiata. The patient’s course was complicated by severe rhabdomyolysis and acute kidney injury requiring emergent dialysis, with concern for compartment syndrome. This case highlights the diagnostic complexity of mixed stimulant-opioid exposure and demonstrates how prolonged immobilization, positional airway protection, and delayed recognition of mixed toxidromes can influence survival outcomes following polysubstance overdose.
Au et al. (Wed,) studied this question.