“Smoking” guns: Questions

A 17-year-old male presented to the hospital following a TASER (TASER International, Inc., Scottsdale, AZ, USA) encounter and arrest by law enforcement. The patient exhibited agitation and aggressive behavior. He admitted to smoking “synthetic marijuana” as well as taking two tablets of combination oxycodone and acetaminophen (Percocet). He complained of retrosternal and upper abdominal pain. He recently acquired a new supply of “Brain Freeze” and smoked it multiple times in the last couple of days including the day of admission. On exam he was tachycardic (heart rate 120 beats per minute) and hypertensive (151/73 mmHg). His abdomen was soft. He had mild non-localizing tenderness. He had bilateral costovertebral angle tenderness. Laboratory evaluation was remarkable for a serum bicarbonate of 8 mmol/l with an anion gap of 29; creatinine 1.7 mg/dl; potassium 3.3 mmol/l; an elevated creatinine kinase (CK) of 2,723 U/l with myoglobinemia 3974.5 ng/ml (Table 1). Urinalysis revealed a