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Agitation after an overdose AUTHOR Dr Vember Ng August, 2013 HKCEM College Tutorial.

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Presentation on theme: "Agitation after an overdose AUTHOR Dr Vember Ng August, 2013 HKCEM College Tutorial."— Presentation transcript:

1 Agitation after an overdose AUTHOR Dr Vember Ng August, 2013 HKCEM College Tutorial

2 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

3

4 Physical Findings ▪ Agitated, generalized muscle twitching ▪ Dehydrated ▪ GCS E2V4M5, pupils 4mm ▪ Chest: clear, ▪ Abd: soft non-tender ▪ CVS: HS dual no murmur

5 ▪ List out the problems ­ Fever ­ Tachycardia ­ Altered LOC, confusion, agitation ▪ List out the Ddx. ­ e.g. AEIOU TIPS

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

7 What is your immediate management? What immediate investigations will you order?

8 ▪ ABC ▪ Restraint (Physical/ Chemical) ▪ Hstix 6.7 ▪ CXR : lungs clear, no cardiomegaly ▪ ECG

9 ECG

10 What is your further management ? Any other investigations ?

11 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)

12 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

13 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

14 Chemical Restraint ▪ Which Drugs ? ▪ Which Benzodiazepine ? ▪ Dose? ▪ Any other alternatives ? ▪ Is it safer to use more physical restraint instead of high dose sedation ?

15 Progress ▪ Diazepam 10mg IVI was given ▪ Still grossly agitated ▪ What will you do next?

16 Progress ▪ Another Diazepam 20mg IVI was given ▪ Still grossly agitated ▪ What will you do next?

17 ▪ If further Diazepam up to 100mg given, ▪ What will you do next ? ▪ Consider, e.g. - More Diazepam - Midazolam infusion - Lorazepam - Morphine - Propofol infusion - RSI…..

18 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

19 Drug Abuse

20 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)

21 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

22 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)

23 Amphetamines and its derivatives

24 >200 amphetamine derivatives or amphetamine-like substances 冰 凍嘢 ( 甲基安非他命 )) E 仔, 糖

25 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.

26 Methamphetamine 路德會青怡中心提供 © Lutheran Evergreen Centre “僕”冰“僕”冰

27 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

28 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)

29 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

30 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

31 Treatment for seizure ▪ Benzodiazepine ▪ Phenytoin is NOT recommended ▪ Rule out hyponatriemia & intracranial pathology

32 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

33 END


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