Presentation on theme: "Agitation after an overdose AUTHOR Dr Vember Ng August, 2013 HKCEM College Tutorial."— Presentation transcript:
Agitation after an overdose AUTHOR Dr Vember Ng August, 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, SpO 2 95% in RA, ▪ Temp 40.6 o C axilla ▪ GCS 11/15 with E2V4M5, pupils dilated ▪ Past Health : unknown
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 of Abuse (Conventional) TypesExamples CNS StimulantsAmphetamines and its derivatives Cocaine / Crack cocaine CNS DepressantsBenzodiazepines Organic solvent inhalation Opioids Gamma-Hydroxybutyrate (GHB) Ethanol Barbiturates DissociativesKetamine Dextromethorphan (e.g. cough mixture) Phencyclidine HallucinogensCannabis Anticholinergics Lysergic 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 TypesGroupExamples 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)
>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 ▪ 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
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