Agitation after an

overdoseAUTHORDr Vember NgAugust, 2013

HKCEM College Tutorial

Triage Findings at 20:37

▪ M/27 ▪ Found running on the street▪ Confusion ? Drunk

▪ BP 180/95, P 180/min, ▪ RR 28/min, SpO2 95% in RA, ▪ Temp 40.6oC axilla▪ GCS 11/15 with E2V4M5, pupils dilated

▪ Past Health : unknown

Physical Findings

▪ Agitated, generalized muscle twitching▪ Dehydrated▪ GCS E2V4M5, pupils 4mm

▪ Chest: clear, ▪ Abd: soft non-tender▪ CVS: HS dual no murmur

▪ List out the problems­ Fever­ Tachycardia­ Altered LOC, confusion, agitation

▪ List out the Ddx. ­ e.g. AEIOU TIPS

Ddx

▪ Drug toxicity▪ Infection, encephalitis, meningitis▪ Heat stroke & heat exhaustion▪ Neuroleptic malignant syndrome▪ Hyperthyroidism, thyroid storm

What is your immediate management?

What immediate investigations will you order?

▪ ABC

▪ Restraint (Physical/ Chemical)

▪ Hstix 6.7

▪ CXR : lungs clear, no cardiomegaly

▪ ECG

ECG

What is your further management ?

Any other investigations ?

Any other tests may be useful ?

▪ ABG▪ Electrolyte▪ CK (rhabdomyolysis)▪ Baseline L/RFT, CBC, cardiac enzymes▪ CT Brain▪ Toxicology screen▪ Bedside urine immunoassay kit (e.g. ACON) ▪ AXR (possibility of body packer)

Bedside urine immunoassay kit (e.g. ACON)

▪MET (Methamphetamine) Positive

▪ Interpretation? ­ Positive results are generally expected up to

several days after their uses­ Clinical utility of bedside kit is limited as both

false positive or false negative are common

Management in AED

▪ ABC +/- Intubation +/- GI decontamination▪ Oxygen▪ IVF▪ Passive cooling (How?)▪ Physical Restraint▪ Chemical Restraint▪ How about tachycardia ? (Use of beta-blocker?)▪ ICU consultation

Chemical Restraint

▪Which Drugs ?

▪Which Benzodiazepine ?

▪ Dose?

▪ Any other alternatives ?

▪ Is it safer to use more physical restraint instead of high dose sedation ?

Progress

▪ Diazepam 10mg IVI was given

▪ Still grossly agitated

▪What will you do next?

Progress

▪ Another Diazepam 20mg IVI was given

▪ Still grossly agitated

▪What will you do next?

▪ If further Diazepam up to 100mg given,

▪What will you do next ?

▪ Consider, e.g. - More Diazepam- Midazolam infusion- Lorazepam- Morphine- Propofol infusion- RSI…..

Progress of our patient

▪ Clinically improving after diazepam 50mg given ▪ No need for intubation (AC not given)

▪ AXR: no FB seen

▪ Cr up to 199, CK 10324, Urine myoglobin +ve▪ Vigorous IVF given

The next day ▪ regained full consciousness ▪ Upon re-questioning, patient admitted that he had taken

some “ice” before collapse

Drug Abuse

Drug of Abuse (Conventional)

Types Examples

CNS Stimulants Amphetamines and its derivativesCocaine / Crack cocaine

CNS Depressants BenzodiazepinesOrganic solvent inhalationOpioids Gamma-Hydroxybutyrate (GHB)EthanolBarbiturates

Dissociatives KetamineDextromethorphan (e.g. cough mixture)Phencyclidine

Hallucinogens CannabisAnticholinergicsLysergic acid diethyamide (LSD)

Emerging Drug of Abuse

▪ Designer drugs, a major component of emerging drug abuse, are drugs produced by illicit chemists to avoid existing drug laws▪ By preparing analogs or derivatives of existing drugs, or less commonly by

finding drugs that mimics the illegal drug effect

▪ Pharmacology, toxicokinetics & toxicodynamics are not well characterized

▪ Difficult to predict the toxicities & the risks involved with their use are often unknown. These drugs are usually more dangerous.

▪ Clinical experience in managing these drugs poisoning is limited

Emerging Drug of Abuse

Types Group Examples

Stimulants • Piperazine-based • Cathinone derivatives

• TFMPP (3-trifluoromethylphenylpiperazine)• BZP (1-benzylpiperazine)• MDPV (Methylenedioxypyrovalerone )• Mephedrone (4-methylmethcathinone)

Hallucinogens • Tryptamine-based • Phenethylamine-based • Ketamine-like• Synthetic Cannabinoids

• 5-methoxy-di-isopropyltryptamine• Mescaline• Methoxetamine• Spice / K2

Others • Salvia divinorum (Salvinorin A)• Poppers (Alkyl Nitrite)

Amphetamines and its derivatives

>200 amphetamine derivatives or amphetamine-like substances

冰 凍嘢( 甲基安非他命 ))

E 仔 , 糖

Methamphetamine

▪ A common recreational drug abused for its stimulant and euphoric effects

▪ The commonest form is crystal, but it can be formulated into “ectasy-like pills” or in the liquid form

▪ Street names include 冰 , ice, crystal meth, speed, crank etc.

▪ The commonest administrative route is smoked through an under-water bottle, however it can be snorted, orally taken, injected and even used per rectal.

Methamphetamine

路德會青怡中心提供

©­Lutheran­Evergreen­Centre

“僕”冰

Methamphetamine

▪ Primary mechanism of action - release of endogenous monoamines (e.g. noradrenaline, serotonin and

dopamine), resulting in sympathomimetic poisoning and psychomotor agitation

▪ Different amphetamines and its derivatives have different potencies

▪ Rapidly absorbed from GI tract, nasal mucosa and respiratory tract, mainly metabolized by liver and excreted in urine

▪ Typically, inhalational and parenteral injection routes give faster and more intense effects than ingestion. The effects usually occur within mins. Acute effects may last > 24 hrs

Clinical Features▪ Classical sympathomimetic toxidrome: ▪ psychomotor agitation, tachycardia, hypertension, diaphoresis, mydriasis

and hyperthermia

Reported major end-organ toxicity:

▪ CNS : Seizure, intracranial bleeding, TIA, infarct.

▪ CVS : ACS, hypertensive emergencies, acute aortic syndrome, arrhythmias, vasospasm

▪ Respiratory :Pneumothorax, pneumomediastinum

▪ Psychiatric: Aggression, paranoid psychosis, mood disturbances

▪ Others : Serotonin syndrome, hyponatremia, hyperthermia, DIC, rhabdomyolysis, ARF, met-bug (delusion of parasitosis)

Management

▪ Rapid “Cooling”, use of benzodiazepines and supportive measures are the mainstay of treatment

▪ Consider GI decontamination if presented promptly after an oral overdose

▪ Rapid cooling measures for hyperthermia

▪ Adequate hydration & other supportive measures

Treatment for agitation

▪ Liberal use of benzodiazepines in titrated manner- Start with 5-10mg diazepam IVI- From experience, 1-2 mg/kg diazepam or its equivalent in the

first 30 min may be required to achieve adequate control of agitation.

▪ Prolonged physical restrain without chemical restrain is dangerous

▪ Closely monitor for rhabdomyolysis and hyperthermia

▪ Antipsychotics use in control of agitation in intoxication of amphetamines are generally NOT recommended

Treatment for seizure

▪ Benzodiazepine

▪ Phenytoin is NOT recommended

▪ Rule out hyponatriemia & intracranial pathology

Treatment for hypertensive emergencies

▪ Benzodiazepine and “calm down” the patient is the 1st line treatment

▪ Titrate with short acting nitrate e.g. nitroprusside▪ Consider phentolamine if inadequate response

▪ Beta-blockers should be avoided since unopposed alpha-adrenergic properties may lead to hypertensive crises

END