Timothy B. Erickson, MD Professor: Department of Emergency Medicine University of Illinois @ Chicago...

Timothy B. Erickson, MDTimothy B. Erickson, MDProfessor: Department of Emergency Professor: Department of Emergency MedicineMedicineUniversity of Illinois @ ChicagoUniversity of Illinois @ Chicago

Street Drugs of AbuseStreet Drugs of Abuse

Case #1 HistoryCase #1 History

A 25 yr old male is found A 25 yr old male is found unresponsive by friends at an unresponsive by friends at an inner city night club called the inner city night club called the “Passion Pit”. He is brought to “Passion Pit”. He is brought to your ER by paramedics. your ER by paramedics.

Physical ExamPhysical Exam

Gen: Disheveled appearance, shallow Gen: Disheveled appearance, shallow breathing, responds to painful stimulibreathing, responds to painful stimuli

Vitals: P=56 RR=6 BP=110/70 Vitals: P=56 RR=6 BP=110/70 T=95T=95

Head: NC/ATHead: NC/AT Eyes: Pinpoint pupilsEyes: Pinpoint pupils Neck: Nontender no deformityNeck: Nontender no deformity Lungs: Poor inspiratory effort, CTA Lungs: Poor inspiratory effort, CTA

Physical ExamPhysical Exam

CV: Bradycardic RRR S1S2 no m’sCV: Bradycardic RRR S1S2 no m’s Abd: Soft with hypoactive BSAbd: Soft with hypoactive BS Rectal: Normal tone (-)HemeRectal: Normal tone (-)Heme G/U: Half-melted ice cubes placed on G/U: Half-melted ice cubes placed on

groin by friends at nightclubgroin by friends at nightclub Neuro: Moves all 4 ext, nonfocalNeuro: Moves all 4 ext, nonfocal Skin: Cool, Arms with needle tracksSkin: Cool, Arms with needle tracks

Case DiscussionCase Discussion

What are your priorities when What are your priorities when managing this patient?managing this patient?

Management PrioritiesManagement Priorities

AirwayAirway BreathingBreathing CirculationCirculation Assess for signs of traumaAssess for signs of trauma Antidote administrationAntidote administration

Case SummaryCase Summary

Comatose patientComatose patient Pinpoint (miotic) pupilsPinpoint (miotic) pupils Depressed respiratory driveDepressed respiratory drive BradycardiaBradycardia HypothermiaHypothermia

Opioid OverdoseOpioid Overdose

HeroinHeroin MethadoneMethadone CodeineCodeine MorphineMorphine FentanylFentanyl DemeralDemeral PropoxyphenePropoxyphene

HEROINHEROIN

ANTIDOTEANTIDOTE

NALOXONENALOXONE

Indicated in comatose patients Indicated in comatose patients with suspected drug overdosewith suspected drug overdose

Restrain patient prior to Restrain patient prior to administrationadministration

Dose: 2-10mg IVPDose: 2-10mg IVP Short half life (T1/2)Short half life (T1/2) Naloxone drip may be requiredNaloxone drip may be required

Clinical Course Clinical Course

After administration of 2mg of After administration of 2mg of naloxone, the patient becomes naloxone, the patient becomes more alert and begins to more alert and begins to verbalize with spontaneous verbalize with spontaneous respiratory activity.respiratory activity.

His vital signs are stable with NSR His vital signs are stable with NSR noted on the cardiac monitor.noted on the cardiac monitor.

Clinical CourseClinical Course

Laboratory data including ECG Laboratory data including ECG and CXR are unremarkable.and CXR are unremarkable.

The toxicology screen is positive The toxicology screen is positive for opiates.for opiates.


The patient denies suicidal The patient denies suicidal ideations and admits to frequent ideations and admits to frequent chronic IV heroin abuse claiming chronic IV heroin abuse claiming “I just had a bad cut tonight.”“I just had a bad cut tonight.”

He becomes more uncooperative He becomes more uncooperative and demands to be discharged….and demands to be discharged….

Case#2 HistoryCase#2 History

The patient is a 28 yr old male who The patient is a 28 yr old male who presents in police custody complaining presents in police custody complaining of chest pain. He has no prior history of of chest pain. He has no prior history of cardiac disease.cardiac disease.

The patient was arrested at the local The patient was arrested at the local international airport for combative international airport for combative behavior while standing in line near the behavior while standing in line near the security area.security area.

Case Physical ExamCase Physical Exam

Gen: Patient is very agitated, Gen: Patient is very agitated, clutching his chestclutching his chest

Vitals: P= 140 BP= 220/130 RR= Vitals: P= 140 BP= 220/130 RR= 28 T=103.2 F28 T=103.2 F

Eyes: Pupils equal: 7mm Eyes: Pupils equal: 7mm Lungs: CTALungs: CTA Ht: RRR S1S2 2/6 systolic murmur Ht: RRR S1S2 2/6 systolic murmur

PHYSICAL EXAMPHYSICAL EXAM

Abd: Distended with diffuse Abd: Distended with diffuse tenderness, hyperactive BStenderness, hyperactive BS

Ext: Good pulse, no cyanosis, Ext: Good pulse, no cyanosis, no needle tracks no needle tracks

Neuro: No focal defs Neuro: No focal defs Skin: DiaphoreticSkin: Diaphoretic

““I’m having chest I’m having chest pain”pain”


The patient now admits to The patient now admits to swallowing several “condoms full swallowing several “condoms full of cocaine” before boarding the of cocaine” before boarding the plane from Columbia to the U.S.plane from Columbia to the U.S.

Drug SmugglersDrug Smugglers

Describe the difference between Describe the difference between a “Body Packer” and a “Body a “Body Packer” and a “Body Stuffer”Stuffer”

Packers and StuffersPackers and Stuffers

Body PackersBody Packers: Drug smugglers who : Drug smugglers who ingest large amounts of pure illegal ingest large amounts of pure illegal contraband methodically wrapped in contraband methodically wrapped in order to deliver “the goods” across order to deliver “the goods” across international borders.international borders.

Body StuffersBody Stuffers: Individuals who : Individuals who “swallow the evidence” during drug “swallow the evidence” during drug raids (poorly wrapped but less pure).raids (poorly wrapped but less pure).

Body StufferBody Stuffer

Body PackerBody Packer

CocaineCocaine

Cocaine hydrochlorideCocaine hydrochloride= usual street = usual street preparationpreparation

Freebase cocaineFreebase cocaine(cocaine alkaloid)= cocaine is (cocaine alkaloid)= cocaine is extracted with alkaline (buffered ammonia) and extracted with alkaline (buffered ammonia) and solvent is added(acetone). Freebase pops or solvent is added(acetone). Freebase pops or cracks when heated hence the term “crack”cracks when heated hence the term “crack”

Rock of crackRock of crack= cocaine hydrochloride heated = cocaine hydrochloride heated with baking soda until a rock is formed-these are with baking soda until a rock is formed-these are smoked in paraphernaliasmoked in paraphernalia

SpeedballSpeedball-heroin laced with cocaine-no narcan-heroin laced with cocaine-no narcan

Cocaine Toxicity Cocaine Toxicity (Sympathomimetic)(Sympathomimetic)

HypertensionHypertension TachycaridaTachycarida HyperthermiaHyperthermia DiaphoresisDiaphoresis AnxietyAnxiety SeizuresSeizures CVA/Intracranial bleedCVA/Intracranial bleed Myocardial infarctionMyocardial infarction

Gastric Gastric DecontaminationDecontamination Activated charcaolActivated charcaol Polyethlene glycol solution Polyethlene glycol solution

(aka: Go-lytely)(aka: Go-lytely) Surgical removalSurgical removal

Cocaine & Chest PainCocaine & Chest Pain

OxygenOxygen BenzodiazepinesBenzodiazepines NitroglycerinNitroglycerin B-Blockers- contraindicatedB-Blockers- contraindicated Hypertension controlHypertension control Thrombolytic Agents (TPA)Thrombolytic Agents (TPA) Cath Lab / AngioplastyCath Lab / Angioplasty


The patient’s chest pain and The patient’s chest pain and hypertension resolves with large hypertension resolves with large doses of NTG and doses of NTG and benzodiazepinesbenzodiazepines

The patient is administered The patient is administered activated charcoal and PEG activated charcoal and PEG solution by the ER physician.solution by the ER physician.


Because of the ST segment Because of the ST segment elevations on ECG, the elevations on ECG, the cardiologist elects to give TPA.cardiologist elects to give TPA.

Since thrombolytics were given, Since thrombolytics were given, the general surgeon refuses to the general surgeon refuses to take the patient to the OR for an take the patient to the OR for an exploratory lap and removal of exploratory lap and removal of the cocaine packets.the cocaine packets.


The patient subsequently The patient subsequently develops seizure activity, develops seizure activity, worsening hyperthermia, worsening hyperthermia, rhabdomyolysis, and intracranial rhabdomyolysis, and intracranial hemorrhage. hemorrhage.

He expires 48 hrs after admission He expires 48 hrs after admission

Case #3 HistoryCase #3 History

•17 y/o CF presents to the community 17 y/o CF presents to the community hospital emergency department at hospital emergency department at 2:00AM with “fever and strange 2:00AM with “fever and strange behavior” as per her parents.behavior” as per her parents.

•While waiting to be examined, the While waiting to be examined, the patient has a witnessed tonic-clonic patient has a witnessed tonic-clonic seizure lasting 1 minute in duration. seizure lasting 1 minute in duration.

No PMH; No medications ; NKDANo PMH; No medications ; NKDA

Vitals: T=104.2F P=120 Vitals: T=104.2F P=120 BP=100/90 RR=28BP=100/90 RR=28

PE: Gen: restless, agitated, confusedPE: Gen: restless, agitated, confused

HEENT: pupils 6mm & reactive, MMMHEENT: pupils 6mm & reactive, MMM

CV: RRR, no MRG Lungs: CTACV: RRR, no MRG Lungs: CTA

Abd: Soft, (+)BS, mild tendernessAbd: Soft, (+)BS, mild tenderness

Skin: warm, dry, no rashesSkin: warm, dry, no rashes

Neuro: No focal defsNeuro: No focal defs

DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

CBC: WNLCBC: WNL Lytes: 120/3.9/87/21Lytes: 120/3.9/87/21 Serum Osm=234, Urine Osm=261Serum Osm=234, Urine Osm=261 Urine Na: 82Urine Na: 82 U/A: large blood (-)RBCsU/A: large blood (-)RBCs CPK: 3,300CPK: 3,300 CT head: normalCT head: normal

Earlier that night:Earlier that night:

•Urine Tox Screen:

+ Amphetamines

+ Cannabis

- EtOH, ASA, APAP

AMPHETAMINESAMPHETAMINES

Ecstasy: The drug of a Ecstasy: The drug of a new generation.new generation.

Ecstasy = MDMAEcstasy = MDMA

3,4 methylenedioxymethamphetamine3,4 methylenedioxymethamphetamine X, E, M, XTC, Rolls, Adam, Bean, Hug DrugX, E, M, XTC, Rolls, Adam, Bean, Hug Drug

MDMA MDMA Properties and Mechanism of Properties and Mechanism of ActionAction Designer drug from the essential oil of Designer drug from the essential oil of

the sassafras treethe sassafras tree Ring substituted amphetamineRing substituted amphetamine Pharmacological effects are a blend of Pharmacological effects are a blend of

amphetamines and mescalineamphetamines and mescaline Structure resembles natural Structure resembles natural

neurotransmitters of Epi, DAneurotransmitters of Epi, DA Biological actions and effects resemble Biological actions and effects resemble

those of Epi, DA, and serotoninthose of Epi, DA, and serotonin

PharmacodynamicsPharmacodynamics

Increases the net release of monoamine Increases the net release of monoamine neurotransmitters (5-HT, NE, DA) from neurotransmitters (5-HT, NE, DA) from their axon terminalstheir axon terminals

MDMA binds to and blocks the serotonin MDMA binds to and blocks the serotonin reuptake transporter – flooding the reuptake transporter – flooding the terminals with 5-HTterminals with 5-HT

Similar, weaker action on DA reuptakeSimilar, weaker action on DA reuptake Amphetamine like increase in NE Amphetamine like increase in NE Increase in 5-HT and DA = mental effectsIncrease in 5-HT and DA = mental effects Increased NE=physical amphetamine Increased NE=physical amphetamine

effectseffects

MDMA analoguesMDMA analogues

MDA (3,4-methylenedioxyamphetamine) – MDA (3,4-methylenedioxyamphetamine) –

“ “Love Drug” - similar in effect, more Love Drug” - similar in effect, more stimulating, twice as neurotoxicstimulating, twice as neurotoxic

MDE (N-ethyl-MDE (N-ethyl-methylenedioxyamphetamine)methylenedioxyamphetamine)

“ “Eve” – more introspective experienceEve” – more introspective experience MMDA (3-methoxy-4,5-MMDA (3-methoxy-4,5-

methylenedioxyamphetamine) – closed methylenedioxyamphetamine) – closed eye hallucinations, “brain movies”eye hallucinations, “brain movies”

MBDB (N-methyl-1-(1,3-benzodioxol-5-yl)-MBDB (N-methyl-1-(1,3-benzodioxol-5-yl)-2-butanamine) – effects similar to MDA2-butanamine) – effects similar to MDA

MDMA HistoryMDMA History

1912 – first synthesized by Merck1912 – first synthesized by Merck 1914 – patented by Merck – 1914 – patented by Merck –

manufactured as an appetite manufactured as an appetite suppressant, never marketedsuppressant, never marketed

1950’s- studied by US Army as potential 1950’s- studied by US Army as potential agent in psychological warfareagent in psychological warfare

1970 – used in psychotherapy, 1970 – used in psychotherapy, “penicillin for the soul”“penicillin for the soul”

1977 – class A illegal drug in UK1977 – class A illegal drug in UK 1985 – Schedule I illegal1985 – Schedule I illegal drug in U.S.drug in U.S.

Trends in Ecstasy UseTrends in Ecstasy Use

DEA seizures of DEA seizures of Ecstasy Tablets:Ecstasy Tablets:

1996 – 13,342 1996 – 13,342 tabletstablets

2000 – 949,257 2000 – 949,257 tabletstablets

2001 - >4,000,000 2001 - >4,000,000 tablets in 8 tablets in 8 monthsmonths

Ecstasy Use by Ecstasy Use by Students, 2000 Students, 2000 (NIDA Studies)(NIDA Studies)

88thth--GradersGraders



Ever Ever UsedUsed

4.3%4.3% 7.3%7.3% 11.0%11.0%

Used in Used in Past Year Past Year (1999)(1999)

3.1% 3.1% (1.7%)(1.7%)

5.4% 5.4% (4.4%)(4.4%)

8.2% 8.2% (5.6%)(5.6%)

Past Past month month useuse

1.4%1.4% 2.6%2.6% 3.6%3.6%

Perceived availability by 12th graders 51.4% (40.1%)

MDMA MDMA Production and SalesProduction and Sales Street value = $25 per pillStreet value = $25 per pill Wholesale price = $2-$8 per pillWholesale price = $2-$8 per pill Production cost = 2-5 cents per pillProduction cost = 2-5 cents per pill Majority of production and Majority of production and

distribution linked to well organized distribution linked to well organized crime networks in Europe crime networks in Europe (Amsterdam, Germany, UK) and (Amsterdam, Germany, UK) and IsraelIsrael

Smaller labs all over US and Europe Smaller labs all over US and Europe

Areas of UsageAreas of Usage

Highest at raves, Highest at raves, dance clubs (as dance clubs (as high as 91% of high as 91% of clubbers in dance clubbers in dance scene in Scotland)scene in Scotland)

Dramatic increase Dramatic increase in college use, in college use, suburban teens, suburban teens, house partieshouse parties

Millroy, CM, JRSM February 1999

Physical CLUESPhysical CLUES

Glowsticks or Glowsticks or lightslights

LollipopsLollipops PacifiersPacifiers Vick’s Vapor Rub Vick’s Vapor Rub

and Nasal Inhalerand Nasal Inhaler Fuzzy MittensFuzzy Mittens

Most Predictive Factor of Drug Use = CLUB MUSIC!

Methods of Methods of AdministrationAdministration Mainly PO – stamped tablets, capsulesMainly PO – stamped tablets, capsules Intra-nasal – rapid absorption of crushed Intra-nasal – rapid absorption of crushed

tablets or opened capsulestablets or opened capsules Intra-rectal – faster absorption than POIntra-rectal – faster absorption than PO Recreational usage varies from ½ pill to Recreational usage varies from ½ pill to

as much 15 pills in a 6 hour spanas much 15 pills in a 6 hour span

Content and PurityContent and Purity

Numerous logos and names (Green Nike, Numerous logos and names (Green Nike, Mitsubishi, Buddha, Smiley Face)Mitsubishi, Buddha, Smiley Face)

Pills tested and results posted on Internet Pills tested and results posted on Internet sites such as dancesafe.orgsites such as dancesafe.org

Average MDMA content 90-100mg/pillAverage MDMA content 90-100mg/pill 60% MDMA, 20% MDEA, 10% MBDB, 10% 60% MDMA, 20% MDEA, 10% MBDB, 10%

no active ingredient or aspirin, 5% no active ingredient or aspirin, 5% amphetamine, ephedrine, or caffeineamphetamine, ephedrine, or caffeine

Millroy, CM, JRSM February 1999

MDMA Adulterants MDMA Adulterants

MDEAMDEA MBDBMBDB MDAMDA PMAPMA CaffeineCaffeine DextromorphanDextromorphan AspirinAspirin PiracetamPiracetam

MethamphetamineMethamphetamine PCPPCP KetamineKetamine HeroinHeroin QuinineQuinine LSDLSD MarijuanaMarijuana EphedrineEphedrine

MDMAMDMA

OnsetOnset 20-90 20-90 minmin

Rise Rise upup

5-20 5-20 minmin

PlateaPlateauu

2-3 2-3 hourshours

Come Come downdown

1-2 1-2 hourshours

After After EffectsEffects

3-24 3-24 hrshrs

PharmacokineticsPharmacokinetics

Peak plasma concentration at ≈ 2 Peak plasma concentration at ≈ 2 hrs 106ng/mL@50mg, hrs 106ng/mL@50mg, 236ng/mL@125mg236ng/mL@125mg

Large tissue distributionLarge tissue distribution Metabolic breakdown by CYP2D6Metabolic breakdown by CYP2D6 Saturation kinetics Saturation kinetics TT1/2 1/2 ≈ 8 hours≈ 8 hours Pharmacologically active first Pharmacologically active first

metabolite (MDA)metabolite (MDA)Kalant, H; Canadian Medical Association Journal, October, 2001

Positive EffectsPositive Effects

Extreme Extreme euphoriaeuphoria

Increased energyIncreased energy Feelings of Feelings of

belonging and belonging and closenesscloseness

Heightened Heightened sensations sensations (touch, taste, (touch, taste, smell, hearing)smell, hearing)

Increased Increased opennessopenness

Feelings of love Feelings of love and empathyand empathy

Bright, intense Bright, intense visual perceptionsvisual perceptions

Musical Musical appreciationappreciation

Fear dissolutionFear dissolution ““Profound” thoughtProfound” thought

Other EffectsOther Effects

Appetite lossAppetite loss Vertical Vertical

nystagmus nystagmus (rolling)(rolling)

Moderate Moderate increases in HR increases in HR and BP and BP

Mild visual Mild visual hallucinationshallucinations

Mind racingMind racing

Changes in Changes in thermoregulationthermoregulation

Restlessness, Restlessness, nervousness, nervousness, shiveringshivering

Strong desire to Strong desire to take more drug take more drug during come during come downdown

MydriasisMydriasis

Negative Side EffectsNegative Side Effects

Mild to extreme Mild to extreme trisma and trisma and bruxismbruxism

Short-memory lossShort-memory loss ConfusionConfusion HA, vertigo, ataxiaHA, vertigo, ataxia Muscle tensionMuscle tension Nausea & vomitingNausea & vomiting Concentration Concentration

difficultiesdifficulties

““Crash” come Crash” come downdown

Hangover lasting Hangover lasting days to weeksdays to weeks

Depression and Depression and fatigue for up to fatigue for up to a weeka week

Psychological Psychological addictionaddiction

Panic attacksPanic attacks

Major Toxic Major Toxic ComplicatioComplicationsns Hyperthermia/Heat StrokeHyperthermia/Heat Stroke DehydrationDehydration HyponatremiaHyponatremia SIADHSIADH Hepatitis/Liver FailureHepatitis/Liver Failure Rhabdomyolysis/Renal FailureRhabdomyolysis/Renal Failure Neurotoxic EffectsNeurotoxic Effects Acute Psychotic Break/Severe DepressionAcute Psychotic Break/Severe Depression

Death!Death!

Ecstasy Related Ecstasy Related FatalitiesFatalities87 cases reported in the literature 87 cases reported in the literature

caused by:caused by: Hyperpyrexia – 30 Hyperpyrexia – 30 Hepatic – 4 Hepatic – 4 Cardiovascular/Cerebrovascular – 8 Cardiovascular/Cerebrovascular – 8 Cerebral, including Hyponatremia – 9 Cerebral, including Hyponatremia – 9 Drug Related Accidents or Suicide – Drug Related Accidents or Suicide –

1414 Unknown – 22 Unknown – 22

Kalant, H; Canadian Medical Association Journal, October, 2001

Major Physical Toxicity Major Physical Toxicity - Hepatic- Hepatic Mild viral hepatitis – jaundice, enlarged Mild viral hepatitis – jaundice, enlarged

tender liver, elevated LFT’s/Coags – tender liver, elevated LFT’s/Coags – self limited, 2 wks-3 mo, related to self limited, 2 wks-3 mo, related to glutathione decrease and oxidative glutathione decrease and oxidative cell destructioncell destruction

Prolonged hepatitis – slow recovery Prolonged hepatitis – slow recovery with potential permanent fibrosiswith potential permanent fibrosis

Fulminant liver failure – fatal without Fulminant liver failure – fatal without liver transplant liver transplant


Major Physical Toxicity Major Physical Toxicity - Cardiovascular- Cardiovascular NE responsible: HTN and tachycardiaNE responsible: HTN and tachycardia Major intracranial hemorrhageMajor intracranial hemorrhage Petechial hemorrhages – brain and Petechial hemorrhages – brain and

other organsother organs Retinal hemorrhage at autopsyRetinal hemorrhage at autopsy Intravascular thrombosis and CVAIntravascular thrombosis and CVA Serious cardiac dysrhythmiasSerious cardiac dysrhythmias Pulmonary edema/heart failurePulmonary edema/heart failure

Major Physical Major Physical Toxicity- CerebralToxicity- Cerebral Hyponatremia- result of vigorous physical Hyponatremia- result of vigorous physical

activity, profuse sweating, large Na+ loss, activity, profuse sweating, large Na+ loss, excessive water consumption excessive water consumption

SIADH – less common mechanism of water SIADH – less common mechanism of water retention, but can complicate pictureretention, but can complicate picture

Cerebral edema w/hyponatremic seizures – Cerebral edema w/hyponatremic seizures – therapy includes BZD’s and cautious therapy includes BZD’s and cautious replacement of Na with hypertonic salinereplacement of Na with hypertonic saline

Brain stem and cerebellum compressionBrain stem and cerebellum compression

Hyperpyrexic Pattern Hyperpyrexic Pattern of Toxicityof Toxicity Most dangerous form of ecstasy Most dangerous form of ecstasy

induced toxicityinduced toxicity Results from a combo of drug action, Results from a combo of drug action,

intense physical activity, and hot intense physical activity, and hot environmentenvironment

Adulterants such as dextromorphan Adulterants such as dextromorphan can inhibit sweating leading to further can inhibit sweating leading to further heat retentionheat retention

Changes resemble those seen Changes resemble those seen in severe heatstroke in severe heatstroke

Features of Features of HyperpyrexiaHyperpyrexia

Rhabdomyolysis – heat Rhabdomyolysis – heat production and muscle production and muscle necrosisnecrosis

Myoglobinuria and renal failure Myoglobinuria and renal failure – secondary to rhabdomyolysis– secondary to rhabdomyolysis

Hepatic necrosisHepatic necrosis DICDIC

Treatment of Treatment of Hyperpyrexic Pattern of Hyperpyrexic Pattern of ToxicityToxicity Mainly symptomatic – rehydration, Mainly symptomatic – rehydration,

monitor electrolytes, treat possible co-monitor electrolytes, treat possible co-ingestionsingestions

Early rapid cooling measures: ice-water Early rapid cooling measures: ice-water sponging, IV infusion of chilled saline, sponging, IV infusion of chilled saline, gastric and bladder lavage with cooled gastric and bladder lavage with cooled fluids, general supportive carefluids, general supportive care

Dantrolene - 1mg/kg – good evidence for Dantrolene - 1mg/kg – good evidence for use as a potential life-saving measureuse as a potential life-saving measure


Toxic Blood LevelsToxic Blood Levels

Poor correlation overall – shows Poor correlation overall – shows importance of environmental importance of environmental factorsfactors

““Recreational” use: 100-250ng/mLRecreational” use: 100-250ng/mL Most cases of serious toxicity or Most cases of serious toxicity or

fatality w/ levels from 500ng/mL–fatality w/ levels from 500ng/mL–1010μμg/mL – 40x higher than usual g/mL – 40x higher than usual recreational rangerecreational range

Some cases of serious toxicity w/ Some cases of serious toxicity w/ levels as low as 111-255ng/mLlevels as low as 111-255ng/mL

PMAPMA

ParamethoxyamphetamineParamethoxyamphetamine Pills contain 50mg of PMA, look like Pills contain 50mg of PMA, look like

MDMA tabletsMDMA tablets Longer duration to onset – toxic in Longer duration to onset – toxic in

doses of 60-80mgdoses of 60-80mg Rapid rise in BP and temp leading to Rapid rise in BP and temp leading to

convulsions, coma, and deathconvulsions, coma, and death Responsible for 10 deaths (3 in Responsible for 10 deaths (3 in

suburbs of Chicago)suburbs of Chicago)

Case RevisitedCase Revisited

Supportive care and rapid cooling Supportive care and rapid cooling measuresmeasures

Volume replacement and Na+ Volume replacement and Na+ correction with 3% NScorrection with 3% NS

Labs corrected (Na=137 @ 30 hrs Labs corrected (Na=137 @ 30 hrs after admissionafter admission

VSS, no further seizures, mental status VSS, no further seizures, mental status improved throughout the dayimproved throughout the day

Stable after 3 days in ICUStable after 3 days in ICU

CASE #4 HISTORYCASE #4 HISTORY

The patient is a 23 yr old who The patient is a 23 yr old who suffered a witnessed seizure and suffered a witnessed seizure and is brought to the ED by concerned is brought to the ED by concerned friends.friends.

He has no prior seizure disorder He has no prior seizure disorder and the friends deny history of and the friends deny history of drug use.drug use.


Gen: Comatose, postictalGen: Comatose, postictal Vs: BP=150/90 P=60 RR=20 T=98.7Vs: BP=150/90 P=60 RR=20 T=98.7 HEENT: NC/AT Pupils: 4mm (+)gag reflexHEENT: NC/AT Pupils: 4mm (+)gag reflex Lungs: CTA Ht: RRR S1S2Lungs: CTA Ht: RRR S1S2 Abd: Benign Ext: (-)c/c/e good pulsesAbd: Benign Ext: (-)c/c/e good pulses Neuro: Moves all 4 ext to pain, no focal Neuro: Moves all 4 ext to pain, no focal

defsdefs Skin: Cool diaphoreticSkin: Cool diaphoretic

DIAGNOSTIC STUDIESDIAGNOSTIC STUDIES

CBC: WBC=14.5 H/H=13/38CBC: WBC=14.5 H/H=13/38 Na=140 K=4.2 Cl=105 HCO3=19Na=140 K=4.2 Cl=105 HCO3=19 Glucose: 180 BUN/Cr= 10/0.9Glucose: 180 BUN/Cr= 10/0.9 ABG: pH=7.35 PO2=110 PCO2=35ABG: pH=7.35 PO2=110 PCO2=35

Tox screen: Neg ETOH= 57Tox screen: Neg ETOH= 57 ECG: NSR no ectopy, no ischemiaECG: NSR no ectopy, no ischemia CT Head: No bleed, no mass CT Head: No bleed, no mass

Clinical courseClinical course

No initial response to D50 or naloxoneNo initial response to D50 or naloxone 4 hours after ED presentation, the 4 hours after ED presentation, the

patient becomes more alert and orientedpatient becomes more alert and oriented

He admits to taking 1 tbs of “growth He admits to taking 1 tbs of “growth hormone powder” mixed with H2O 45 hormone powder” mixed with H2O 45 min prior to presentation purchased at a min prior to presentation purchased at a local health food storelocal health food store

The powder had been advertised as a The powder had been advertised as a “muscle builder” “muscle builder”

Gamma Hydroxybutyrate Gamma Hydroxybutyrate

AcidAcid (GHB) (GHB) Liquid ecstacy Liquid ecstacy Liquid GLiquid G Gamma Oh Gamma Oh Grievous bodily harm Grievous bodily harm Scoop Scoop SamatomaxSamatomax Bioski Bioski Cow Growth HormoneCow Growth Hormone Georgia Home BoyGeorgia Home Boy

GHBGHB

Analogue of inhibitory neurotransmitter Analogue of inhibitory neurotransmitter gamma-aminobutyirc acid- CNS gamma-aminobutyirc acid- CNS depressantdepressant

Synthesized in 1960 and used in 1970’s Synthesized in 1960 and used in 1970’s for sleep disorders because it induces for sleep disorders because it induces REM sleepREM sleep

Used in Europe as anesthetic agent until Used in Europe as anesthetic agent until found that it caused seizuresfound that it caused seizures

1977, study claimed it stimulated effects 1977, study claimed it stimulated effects of Growth Hormoneof Growth Hormone

GHB GHB

Unapproved drug in US, but Unapproved drug in US, but legally obtainable under FDA legally obtainable under FDA investigational New Drug investigational New Drug exemption for treatment of exemption for treatment of narcolepsynarcolepsy

–20 states have controlled 20 states have controlled its use with penalties its use with penalties similar to marijuana similar to marijuana possessionpossession

Gamma Hydroxybutyrate Gamma Hydroxybutyrate

AcidAcid (GHB) (GHB)

Readily available in drug market Readily available in drug market and inexpensive and relatively and inexpensive and relatively easy to make easy to make – recipes are obtainable on the recipes are obtainable on the

internetinternet Obtainable as clear and odorless Obtainable as clear and odorless

liquid, gel, or powder which have a liquid, gel, or powder which have a salty tastesalty taste– however, taste is masked by however, taste is masked by

ETOH which increases its clinical ETOH which increases its clinical effectseffects

GHBGHB

Used in date rape because: Used in date rape because:

–quick onset of effectquick onset of effect

– easily obtainableeasily obtainable

– small quantities are neededsmall quantities are needed

–causes hallucinations and causes hallucinations and amnesia making the patient an amnesia making the patient an unreliable witness unreliable witness

GHBGHB

GHB - ToxicityGHB - Toxicity

Acts as neurotransmitter affecting Acts as neurotransmitter affecting GHB and GABA- B receptors causing GHB and GABA- B receptors causing CNS depressionCNS depression– takes effects in 15-30 minutes takes effects in 15-30 minutes

causing drowsiness, dizziness, and causing drowsiness, dizziness, and disorientationdisorientation

– duration of action up to 3 hoursduration of action up to 3 hours– half life of 20 min to 1 hourhalf life of 20 min to 1 hour– hallmark is marked agitation upon hallmark is marked agitation upon

stimulation despite apnea and stimulation despite apnea and hypoxiahypoxia

10mg/kg causes vomiting, 10mg/kg causes vomiting, rapid onset of coma and rapid onset of coma and amnesiaamnesia

20-30mg/kg cause rapid cycles 20-30mg/kg cause rapid cycles of REM and non-REM sleepof REM and non-REM sleep

50mg/kg can cause resp 50mg/kg can cause resp depression, bradycardia, clonic depression, bradycardia, clonic muscle contractions, and muscle contractions, and decreased cardiac outputdecreased cardiac output

GHB - Other formsGHB - Other forms

Gamma butyrolactone (GBL) - can be Gamma butyrolactone (GBL) - can be purchased from chemical supply purchased from chemical supply stores or catalogues and converted to stores or catalogues and converted to GHB with NaOHGHB with NaOH– GBL is rapidly converted to GHB by GBL is rapidly converted to GHB by

peripheral lactonases within peripheral lactonases within minutesminutes

1,4-Butanediol - can be purchased in 1,4-Butanediol - can be purchased in similar manner as GBLsimilar manner as GBL

–converted to gamma converted to gamma hydroxybutyaldehyde by alcohol hydroxybutyaldehyde by alcohol dehydrogenasedehydrogenase

–then, converted to GHB by then, converted to GHB by aldehyde dehydrogenasealdehyde dehydrogenase

GHB - DiagnosisGHB - Diagnosis

High clinical suspicion based on history High clinical suspicion based on history and clinical presentationand clinical presentation– abrupt on set of coma with recovery abrupt on set of coma with recovery

within a few hourswithin a few hours

Lab tests for GHB not readily availableLab tests for GHB not readily available– few national reference labs few national reference labs

Duration of detection of GHB in blood Duration of detection of GHB in blood and urine are 6 and 12 hours, and urine are 6 and 12 hours, respectivelyrespectively

GHB - TreatmentGHB - Treatment

Mainly supportiveMainly supportive Antidotes for GHB: Physostigmine?Antidotes for GHB: Physostigmine? DecontaminationDecontamination

– charcoal has doubtful benefits since charcoal has doubtful benefits since small amounts used are absorbed small amounts used are absorbed rapidly and may increase risk of rapidly and may increase risk of pulmonary aspiration pulmonary aspiration

Enhanced EliminationEnhanced Elimination– no roleno role


The patient is an 18 yr old The patient is an 18 yr old transferred from the H.S. health transferred from the H.S. health center to the ED after he was center to the ED after he was caught wondering the hallways by caught wondering the hallways by the art department the art department demonstrating “bizzare behavior”demonstrating “bizzare behavior”

The patient is normally healthyThe patient is normally healthy


Gen: Sleepy, blank catatonic stare when Gen: Sleepy, blank catatonic stare when awakened, good airwayawakened, good airway

Vs: P=90 BP=110/70 RR=16 T=99Vs: P=90 BP=110/70 RR=16 T=99 HEENT: NC/AT Eyes: Pupils 3mm Rotary HEENT: NC/AT Eyes: Pupils 3mm Rotary

nystagmus noted; moist mm’s nystagmus noted; moist mm’s (+)drooling (+)drooling

Lungs: CTA CV: RRR S1S2Lungs: CTA CV: RRR S1S2 Abd: Benign Ext: Good pulsesAbd: Benign Ext: Good pulses Neuro: Motor sensory grossly intact Neuro: Motor sensory grossly intact

no focal defs no focal defs

KetamineKetamine

KetamineKetamine

AKA: Special K, Super Acid, Super CAKA: Special K, Super Acid, Super C used as an anesthetic in EM and used as an anesthetic in EM and

veterinary medicineveterinary medicine Ketamine is a controlled substance in 18 Ketamine is a controlled substance in 18

states as schedule III drugstates as schedule III drug Used in date rape because:Used in date rape because:

– rapid onsetrapid onset– dissociative hallucinogenic dissociative hallucinogenic

Ketamine - ToxicityKetamine - Toxicity

Chemically related to PCPChemically related to PCP takes effect 15-20 minutes, takes effect 15-20 minutes,

producing analgesiaproducing analgesia Higher doses produces dissociative Higher doses produces dissociative

hallucinations, delirium, resp hallucinations, delirium, resp depresion, Sz, arrythmias and depresion, Sz, arrythmias and cardiac arrestcardiac arrest

Effects last 20-45minEffects last 20-45min

Ketamine - DiagnosisKetamine - Diagnosis

High index of suspicion based High index of suspicion based on history and presentationon history and presentation

Urine tox screens may Urine tox screens may mistakenly ID as PCP since mistakenly ID as PCP since structurally related to PCPstructurally related to PCP

Specific test for ketamine not Specific test for ketamine not widely availablewidely available

Ketamine - TreatmentKetamine - Treatment

Mainly supportiveMainly supportive No antidoteNo antidote Pt should be placed in quiet room Pt should be placed in quiet room

with minimal stimulationwith minimal stimulation


The patient is a 16 yr old male who The patient is a 16 yr old male who presents to the ED complaining of presents to the ED complaining of facial swelling, drooling, and blisters facial swelling, drooling, and blisters on his fingers from “doing a little on his fingers from “doing a little painting”painting”

He also claims that the top of a freon He also claims that the top of a freon propellant can “fell off” while he was propellant can “fell off” while he was sleeping next to it.sleeping next to it.


Gen: Alert, oriented, mild resp Gen: Alert, oriented, mild resp distressdistress

Vs: P=120 RR=28 BP=110/60 T=96Vs: P=120 RR=28 BP=110/60 T=96 HEENT: Extensive edema, scattered HEENT: Extensive edema, scattered

blisters and bullae of the lips, oral blisters and bullae of the lips, oral mucosal/tongue with obvious facial mucosal/tongue with obvious facial deformitydeformity

Lungs: CTA CV: Tachy RRR S1S2 Lungs: CTA CV: Tachy RRR S1S2 Ext: Blisters of distal phalangesExt: Blisters of distal phalanges

LABORATORYLABORATORY

CBC: WBC: 22K Hgb: 11.5CBC: WBC: 22K Hgb: 11.5 Lytes: Na=140 K=2.9 Cl=117 Lytes: Na=140 K=2.9 Cl=117

HCO3=18HCO3=18 BUN/Cr: 29/2.1 Glucose=140BUN/Cr: 29/2.1 Glucose=140 Tox screen: (+)cannabinoidsTox screen: (+)cannabinoids ETOH: 20ETOH: 20 ECG: Sinus tach 120/min, no ischemiaECG: Sinus tach 120/min, no ischemia CXR: No infiltrates or pulm edemaCXR: No infiltrates or pulm edema

DefinitionsDefinitions

VSAs:VSAs: ( (VVolatile olatile SSubstances of ubstances of AAbuse)buse)

““Sniffing”:Sniffing”: inhaling inhaling rawraw vapors. vapors.

““Huffing”:Huffing”: inhaling vapors from inhaling vapors from a a soaked clothsoaked cloth held next to mouth held next to mouth or nose.or nose.

““Bagging”:Bagging”: inhaling vapors from inhaling vapors from a a bagbag, balloon, or other vessel , balloon, or other vessel which is then held over mouth or which is then held over mouth or nose.nose.

Inhalants--Street NamesInhalants--Street Names

Air BlastAir Blast Bullet boltBullet bolt Disco-ramaDisco-rama Head Head

CleanerCleaner Heart-OnHeart-On High BallHigh Ball Hippie CrackHippie Crack Honey OilHoney Oil

HuffHuff

KickKick

MedusaMedusa

Moon GasMoon Gas

OzOz

Satan’s SecretSatan’s Secret

SniffSniff

Toilet WaterToilet Water

HistoryHistory

Ancient Greece: the Pythia sat Ancient Greece: the Pythia sat above a cleft in the rocks and above a cleft in the rocks and inhaled cold vapors emanating inhaled cold vapors emanating from inside the earth, which from inside the earth, which induced an ecstatic alteration of induced an ecstatic alteration of mindmind

Proverbs (27:9) “ointment and Proverbs (27:9) “ointment and perfume rejoice the heart.”perfume rejoice the heart.”

Ether “frolics” and NEther “frolics” and N22O “sniffing O “sniffing parties” starting in 1700s (25 cent parties” starting in 1700s (25 cent admission). admission).

NN22O discovered in 1776 by Sir O discovered in 1776 by Sir Humphrey Davy/Joseph Priestly, used Humphrey Davy/Joseph Priestly, used by Winston Churchill, Samuel Taylor by Winston Churchill, Samuel Taylor Coleridge.Coleridge.

Ether was first used for surgery and Ether was first used for surgery and then sold in the late 1800s as a then sold in the late 1800s as a 'medicinal' for women. 'medicinal' for women.

WW II: Ether used as EtOH WW II: Ether used as EtOH substitute.substitute.

Current abuse trend first noticed in Current abuse trend first noticed in 1950s in California.1950s in California.

(Bass, et al, JAMA June 1970)(Bass, et al, JAMA June 1970)

Robert Hinkley, Robert Hinkley, 18931893

Scope of the ProblemScope of the Problem

Total reported PCC cases: Total reported PCC cases: 2,271,1882,271,188

Inhalation: 138,647 (6.1%)Inhalation: 138,647 (6.1%) Reported PCC fatalities: 1,001Reported PCC fatalities: 1,001 Inhalation fatalities: 85 (8.5%)Inhalation fatalities: 85 (8.5%)

2000 Annual report of the American Association of 2000 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance Poison Control Centers Toxic Exposure Surveillance SystemSystem

Scope of the Scope of the ProblemProblem

Scope of the ProblemScope of the Problem

Brazil: Brazil: Glue sniffing is used as a Glue sniffing is used as a replacement for food. replacement for food.

Egypt, India, Romania,Egypt, India, Romania, Guatemala, Native Canadians: Guatemala, Native Canadians: A A coping mechanism. Children use coping mechanism. Children use VSAs to stay awake for work, to alert VSAs to stay awake for work, to alert toward possible violence, to sleep, or toward possible violence, to sleep, or to dull physical or emotional pain.to dull physical or emotional pain.

VSAs also used in many cultures and VSAs also used in many cultures and countries as social outcries against countries as social outcries against government and society.government and society.

General General Types/ClassificationTypes/Classification Volatile Hydrocarbons/SolventsVolatile Hydrocarbons/Solvents

Volatile NitritesVolatile Nitrites

GasesGases

Volatile Volatile Hydrocarbons/SolventsHydrocarbons/Solvents

~2/3

Total: 165 cases

Spiller HA, Krenzelok EP. (1997) Kentucky RPC, Pittsburgh PC.

Substances Involved in Inhalant Abuse Cases

Volatile Substances of Abuse Commonly Found in Commercial

Products

Volatile Nitrites Volatile Nitrites (poppers)(poppers)

““Offer good until November Offer good until November 30th”30th”

Gases/AerosolsGases/Aerosols

Total: 165 cases

Spiller HA, Krenzelok EP. (1997) Kentucky RPC, Pittsburgh PC.

EffectsEffects

Acute Organ System Effects: Acute Organ System Effects: CardiovascularCardiovascular

Myocardial sensitization to Myocardial sensitization to catecholaminescatecholamines

First mentioned by Bass, et al JAMA First mentioned by Bass, et al JAMA 19701970

– Mostly with Solvents/HCsMostly with Solvents/HCs incidence of epinephrine-incidence of epinephrine-

induced dysrhythmia in rats induced dysrhythmia in rats exposed to VSAsexposed to VSAs

– Direct VSA-induced Direct VSA-induced in in endogenous catecholamines endogenous catecholamines

– Arrhythmia ;decreased Arrhythmia ;decreased contractilitycontractility

Acute Organ System Acute Organ System Effects: Effects: PulmonaryPulmonary

Asphyxia: VSA displaces OAsphyxia: VSA displaces O22 HYPOXEMIA (esp NHYPOXEMIA (esp N22O)O)

Direct irritation Direct irritation chemical chemical PNEUMONITISPNEUMONITIS, wheezing, rales, wheezing, rales

Direct CNS effect Direct CNS effect RESPIRATORY DEPRESSION or RESPIRATORY DEPRESSION or arrestarrest

airway reflexes + airway reflexes + N/V N/V ASPIRATIONASPIRATION

VASOVAGAL effect- VASOVAGAL effect- Direct spraying of propellant into Direct spraying of propellant into mouthmouth

Cortical AtrophyCortical Atrophy

Normal brain

Long-Term EffectsLong-Term Effects

Mostly neurologic (rare): Mostly neurologic (rare): – impaired neuro-cognitive functionimpaired neuro-cognitive function

Can also severely affect liver, Can also severely affect liver, kidneys, heart, lungs, bone kidneys, heart, lungs, bone marrowmarrow

Special SituationsSpecial Situations

Typewriter correction fluidTypewriter correction fluid– May contain halogenated HCs: TCE, May contain halogenated HCs: TCE,

ClCl33-ethylene, perchloroethylene-ethylene, perchloroethylene– Cause dysrhythmia, seizure, CNS Cause dysrhythmia, seizure, CNS

depressiondepression– Massive hepatic necrosisMassive hepatic necrosis– Mustard oil recently added as Mustard oil recently added as

irritant to irritant to deliberate inhalation deliberate inhalation

Gasoline- hGasoline- historically, lead level istorically, lead level helpful, but now there is helpful, but now there is use of use of leaded gasleaded gas

Some Some Specific Specific ToxicitieToxicitiess

Pediatric Annals, Pediatric Annals, January 1996.January 1996.

Special SituationsSpecial Situations

Alkyl NitritesAlkyl Nitrites– Can get HYPOTENSION: caution use with Can get HYPOTENSION: caution use with

VIAGRA, other Nitrates (NTG)VIAGRA, other Nitrates (NTG)– MethemoglobinemiaMethemoglobinemia

Methylene ChlorideMethylene Chloride– CO is a metaboliteCO is a metabolite

N2ON2O– HypoxemiaHypoxemia

Ether: Ether: FLAMMABLEFLAMMABLE

Sudden Sniffing DeathSudden Sniffing Death

Mechanism of DeathMechanism of Death– Induce Induce V-fibV-fib. .

Most frequently with Most frequently with toluene toluene and and halogenated HCs:halogenated HCs:

– VSA-induced/catechol sensitized VSA-induced/catechol sensitized myocardiummyocardium Clinical and animal studies Clinical and animal studies

corroborate Bass’ suggestioncorroborate Bass’ suggestion– Hypokalemia: additional cause of Hypokalemia: additional cause of

arrhythmiaarrhythmia

Detection/Identification: Detection/Identification: DemographicDemographic

Males > Females Males > Females Onset: ~6-8 yo Onset: ~6-8 yo Peak age: 14-15 yoPeak age: 14-15 yo Lower socioeconomic statusLower socioeconomic status Poor school performancePoor school performance Family dysfunctionFamily dysfunction Hispanic, Latin American, Native Hispanic, Latin American, Native

AmericansAmericans

Detection/Identification: Detection/Identification: HistoricalHistorical

Rags, bags, empty containersRags, bags, empty containers N/V, loss of appetiteN/V, loss of appetite Irritability/behavior changeIrritability/behavior change DepressionDepression Blindness, Deafness: TolueneBlindness, Deafness: Toluene Numbness: Nitrous OxideNumbness: Nitrous Oxide

HexaneHexane (peripheral (peripheral neuropathy)neuropathy)

XyleneXylene

Detection/Identification: Detection/Identification: ClinicalClinical

Chemical odor on breath or Chemical odor on breath or clothingclothing

Paint stained clothing and/or Paint stained clothing and/or skinskin

““Glue-sniffer’s rash”Glue-sniffer’s rash” DisorientedDisoriented Slurred speechSlurred speech AtaxiaAtaxia Peripheral neuropathyPeripheral neuropathy HypotensionHypotension

Detection/Identification: Detection/Identification: LabLab

– Methylene ChlorideMethylene Chloride CO-Hb level with monitoring for ~12-CO-Hb level with monitoring for ~12-

24h24h

– Alkyl NitriteAlkyl Nitrite MethemglobinemiaMethemglobinemia

– CClCCl44, Chloroform, Xylene, Chloroform, Xylene Watch LFTs closely (acute hepatic Watch LFTs closely (acute hepatic

necrosis)necrosis)

– Lead levelLead level Gasoline?Gasoline?

– Nitrous OxideNitrous Oxide Megaloblastic anemia (B12 def.)Megaloblastic anemia (B12 def.)

Detection/Identification: Detection/Identification: LabLab

Routine Testing:Routine Testing:– CBC, Electrolytes, BUN/CR, CBC, Electrolytes, BUN/CR,

ABG, UA, LFTs, PT/PTT/INRABG, UA, LFTs, PT/PTT/INR

– Tox screen (UDS, serum drug Tox screen (UDS, serum drug screen)screen)

– ECG if symptomaticECG if symptomatic

– CT for non-improving AMSCT for non-improving AMS

– CXR with pulmonary CXR with pulmonary symptomssymptoms

ManagementManagement

– ABCs/ACLSABCs/ACLS– Remove exposure- Remove exposure- – Decontaminate skin/eyesDecontaminate skin/eyes– OxygenOxygen

Hyperventilation: Hyperventilation: pulmonary pulmonary excretionexcretion

– IV: 0.9 NS initially. IV: 0.9 NS initially. Glucose may exacerbate hypokalemiaGlucose may exacerbate hypokalemia

– Electrolyte replacement as needed Electrolyte replacement as needed (K, Ca, P, Mg) (K, Ca, P, Mg)

– Admit: Admit: Psych, if intentional. Psych, if intentional. ((Addiction treatmentAddiction treatment))

ManagementManagement Catecholamine Catecholamine

surge/sensitzationsurge/sensitzation– Sympathomimetic aminesSympathomimetic amines

and pressors should be used and pressors should be used CAUTIOUSLYCAUTIOUSLY 2 2 to sensitized to sensitized myocardium.myocardium.

– Bronchospasm: IBronchospasm: Inhaled nhaled 22--agonistsagonists useful, but may be useful, but may be pro-arrhythmic.pro-arrhythmic.

– Treat seizures/agitation with Treat seizures/agitation with BENZOS firstBENZOS first to avoid excess to avoid excess catecholamine stimulation. catecholamine stimulation.

CARDIACCARDIAC

-blockers -blockers shown in some shown in some cases (limited data/evidence) cases (limited data/evidence) to be helpful to to be helpful to arrhythmias. arrhythmias.

–AmiodaroneAmiodarone may be more may be more helpful for V-fib/arrhythmias helpful for V-fib/arrhythmias (limited data/evidence).(limited data/evidence).

ManagementManagement

Specific TherapiesSpecific Therapies– Amyl NitriteAmyl Nitrite

Methylene Blue for Methylene Blue for MethemoglobinemiaMethemoglobinemia

– Hepatic/Renal Toxicity Hepatic/Renal Toxicity (Chlorofrom, TCE, TC-Ethylene)(Chlorofrom, TCE, TC-Ethylene) N-AcetylcysteineN-Acetylcysteine

– Methylene ChlorideMethylene Chloride 100% O100% O2 2 HBO HBO

Special thanks to:Special thanks to:

Ryan Snitowsky- EcstacyRyan Snitowsky- Ecstacy Joe Garcia- InhalantsJoe Garcia- Inhalants Javier Rangel- GHBJavier Rangel- GHB

ReferencesReferences

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Kalant H. The pharmacology and toxicity of “ecstasy” Kalant H. The pharmacology and toxicity of “ecstasy” (MDMA) and related drugs. CMAJ 2001;165(7):917-928.(MDMA) and related drugs. CMAJ 2001;165(7):917-928.

Milroy CM. Ten years of ecstasy. JRSM 1999;92(2):68-Milroy CM. Ten years of ecstasy. JRSM 1999;92(2):68-72.72.

Schwartz RH, Miller NS. MDMA (Ecstasy) and the rave: Schwartz RH, Miller NS. MDMA (Ecstasy) and the rave: A review. Pediatrics 1997;100(4): 705-708.A review. Pediatrics 1997;100(4): 705-708.

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Gussow, Leon “Inhalants of Abuse” in Gussow, Leon “Inhalants of Abuse” in Clinical Clinical Toxicology, Toxicology, ed. Ford, Delaney, Ling, Erickson ed. Ford, Delaney, Ling, Erickson (Philadelphia, PA: WB Saunders, 2001) pp. 651-656.(Philadelphia, PA: WB Saunders, 2001) pp. 651-656.

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MICROMEDEX, Inc., Greenwood Village, Colorado (Edition expires 12/2001).MICROMEDEX, Inc., Greenwood Village, Colorado (Edition expires 12/2001).

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